Renal Replacement Therapy In Patients Research Articles

Paediatric CRRT and ECMO: fluid overload is not the only issue

Current dogma suggests that fluid overload—when associated with acute kidney injury (AKI)—is an independent risk factor for death. Although the volume status of the patient is important, there are other predictors of morbidity, mortality and the need for renal replacement therapy in patients with AKI.

Renal Replacement Therapy in Patients With HIV Infection in a European Region: Outcomes Following Renal Transplantation

IntroductionThe prognosis of HIV infection has improved dramatically in patients with end-stage renal disease (ESRD). Thus, HIV infection is no longer an absolute contraindication for renal transplantation. MethodsA cross-sectional study was performed to analyze the characteristics of HIV patients receiving renal replacement therapy (RRT) in September 2011, using data from the Registry of Renal Patients in Andalusia. A retrospective cohort study was also carried out, analyzing patients receiving kidney transplants in the era of highly active antiretroviral therapy. ResultsIn Andalusia in September 2011, 8744 patients were on RRT; of these, 48 had HIV infection (prevalence 0.54%). The RRT modality was very different between HIV-negative and HIV-positive patients: renal transplantation 49.2% and 16.7%, hemodialysis 46.8% and 81.3%, and peritoneal dialysis 4% and 2%, respectively. The most frequent ESRD etiology was glomerulonephritis (37.5%). Twenty-seven (56.3%) had hepatitis C coinfection. Only three patients (7.5%) were on the waiting list for renal transplantation. From 2001 to September 2011, 10 HIV-infected patients received a renal transplantation (median follow-up 40.5 months). The initial immunosuppressive treatment included tacrolimus and mycophenolate without induction therapy. Only two patients presented acute rejection, both borderline and corticosensitive. All remain alive and the graft survival was 100% in the first and third years posttransplant. We compared demographic and comorbidity variables between patients transplanted or included on the waiting list (n = 12) and patients excluded and never transplanted (n = 36). We found differences only in the ESRD etiology (higher incidence of glomerulonephritis in excluded patients). ConclusionsRenal transplantation is safe in correctly selected HIV-infected patients. The number of patients on the waiting list is very small. This may reflect the high comorbidity but it is also possible that these patients are still not being assessed systematically for transplant in all centers.

Impact of elevated intact parathyroid hormone on mortality and renal disease progression in patients with chronic kidney disease stages 3 and 4

Objective:To estimate the impact of elevated intact parathyroid hormone levels on time to death and renal replacement therapy in patients with chronic kidney disease stages 3 and 4.Methods:A retrospective cohort analysis from 01/1996 to 09/2007 was conducted in 11,092 patients with chronic kidney disease stages 3 and 4 patients using Cockroft–Gault and Modification of Diet in Renal Disease equations to estimate their glomerular filtration rates. Patients’ highest parathyroid hormone levels were used to define the index date and cohort (followed for 1 year). Mortality and renal replacement therapy events were evaluated among cohorts at pre-defined parathyroid hormone levels.Results:As the intact parathyroid hormone levels increased, the mean age, number of females and estimated glomerular filtration rates decreased. Patients with an intact parathyroid hormone level <50 pg/mL were defined as the reference group. Similar results were found using the Modification of Diet in Renal Disease equation for calculating estimated glomerular filtration rate, which was possible in 48% of the patients where race could be identified. Combined mortality and renal replacement therapy adjusted hazard ratio using Cox regression for intact parathyroid hormone level 51–110 pg/mL was 1.12 (0.82–1.54), intact parathyroid hormone level 111–199 pg/mL was 2.42 (1.78–3.29), intact parathyroid hormone level 200–299 pg/mL was 3.01 (2.14–4.27), intact parathyroid hormone level 300–399 pg/mL was 3.12 (2.09–4.60), intact parathyroid hormone level 400–499 pg/mL was 3.91 (2.61–5.85) and intact parathyroid hormone level >500 pg/mL was 2.67 (1.84–3.84).Conclusion:Intact parathyroid hormone levels >50 pg/mL in patients with chronic kidney disease stages 3 and 4 are associated with an escalating combined risk of death or RRT.

Association of ICU size and annual case volume of renal replacement therapy patients with mortality

We aimed to reveal whether the size of an intensive care unit (ICU) or its annual case volume of patients treated with renal replacement therapy (RRT) for acute kidney injury (AKI) is associated with hospital mortality. This was a retrospective cohort study in the Finnish Intensive Care Consortium (FICC) database in 2007-2008. We divided the 23 FICC-member ICUs first into small or large according to ICU size, and second into low, medium, or high-volume tertiles according to annual case volume of patients with RRT. We compared crude hospital mortality, Simplified Acute Physiology Score (SAPS) II-, and case-mix-adjusted hospital mortality in small vs. large ICUs and in low- or medium-volume vs. high-volume ICUs. The median (interquartile range) annual case volume of patients with RRT for AKI per one ICU was 25 (19-45). Patients in small or low-volume ICUs were older and less severely ill. Crude and SAPS II -adjusted hospital mortality rates were significantly higher in small ICUs but not significantly different in case volume tertiles. After adjusting for age, severity of illness, intensity of care, propensity to receive RRT, and day of RRT initiation, treatment in low or medium volume ICUs was associated with an increased risk for hospital mortality. Crude and adjusted hospital mortality rates of patients treated with RRT for AKI were higher in small ICUs. Patients treated in high-volume ICUs had a decreased adjusted risk for hospital mortality compared to those in low-or medium volume ICUs.

EFFECTS OF A KETO/AMINO ACID SUPPLEMENTED LOW PROTEIN DIET ON THE DELAY OF PROGRESSIEVE RENAL FAILURE IN CHRONIC KIDNEY DISEASE

A protein-restricted diet with keto/amino acids (KA) supplement showed favorable effects on delayed renal replacement therapy in patients with chronic kidney disease. This is an open, prospective, randomized, and multi-center study. A total of 67 patients were randomly assigned into two groups. LPD+KA group was advised to take less than 0.6 g/kg/day of protein with KAs. LPD group was advised to consume less than 0.6 g/kg/day protein. Nutritional and clinical parameters were evaluated at baseline, 3 and 6 months. Nutritional status represented as body mass index, mid-arm circumference and triceps skin-fold thickness was not different between the two groups at 3months and 6 months. Ca×P product level measured at 3 months was lower in the LPD+KA group than in the LPD group (LPD+KA group: 33.5±5.0 vs. LPD group: 36.9±7.9 mg 2 /dL 2 , p

Survival during renal replacement therapy of patients previously treated with a very low-protein diet supplemented with ketoacids : the Italian experience.

In the course of chronic renal failure, low protein-diets allow better control of metabolic disorders and may delay the start of renal replacement therapy (RRT). However, concerns exist that a very low protein diet supplemented with ketoacids (sVLPD) worsens survival after starting RRT. To evaluate whether a prolonged sVLPD regimen may affect all-cause mortality during the following RRT period, we studied time to all-cause death during RRT in patients previously followed in renal clinics either treated with sVLPD (sVLPD group, n =184, age 67±18 yrs) or not (CKD group, n =334, age 66±14 yrs). A Control group including 9,092 patients (age 66±14 yrs) was selected from the Italian dialysis & transplantation registry (RIDT). In sVLPD, CKD and Control groups, the prevalence of an history of cardiovascular disease was 41, 31, 25% and of diabetes was 18%, 31%, 17%, respectively; the median follow-up time in RRT (36, 32, 36 months) did not differ among groups.Cumulative survival was similar in sVLPD and CKD groups ( p =0.638), but significantly higher than in the Control group (Long-rank test, 20,62; p p =0.0001) in sVLPD and 0.65 [0.53−0.80] ( p =0.001) in CKD group. Due to age interaction with survival in sVLPD ( p =0.024), HRs for death reduced to 0.34 [0.16−0.73] and 0.58 [0.37−0.92] in sVLPD and CKD pts In conclusion, prescription of sVLPD during the conservative phase of chronic renal failure does not worsen, or even improves, survival after starting RRT. This survival advantage is more evident in patients younger than 70 years.

Epidemiology of end-stage renal disease and hemodialysis treatment in Serbia at the turn of the millennium

The study presents the epidemiological features of patients treated with renal replacement therapy (RRT) in Serbia from 1997 to 2009 and compares the results of hemodialysis treatment in 1999 and 2009. Epidemiological data were obtained from the National Registry of RRT patients and data on hemodialysis treatment from special surveys conducted in 1999 and 2009. Within the period 1997-2009 the incidence of patients on RRT increased from 108 to 179 per million population (pmp), prevalence rose from 435 to 699 pmp, while mortality rate fell from 20.7% to 16.7%. The frequency of patients with glomerulonephritis decreased, while that of patients with diabetes and hypertensive nephropathy increased. In late 2009 there were 5208 patients receiving RRT in Serbia. Within the examined period new hemodialysis and reverse osmosis equipment were purchased, high-flux dialyzers with synthetic membranes were increasingly used and the number of patients receiving hemodiafiltration increased to 17.6%. Kt/V greater than 1.2 was recorded in 16% of the patients in 1999 but 52% in 2009. Options for correction of anemia and mineral disorders have also improved. The percentage of patients with HbsAg (13.8% vs. 4.8%) as well as anti-hepatitis C virus antibodies positive patients (23.2% vs. 12.7%) was significantly lower in 2009 than in 1999. Both the incidence and prevalence of RRT patients in Serbia are rising continuously, while the mortality rate is falling. More favorable conditions for dialysis treatment have brought about significant improvement in the results over the last 10 years.

Renal allograft nephropathy in patient with type 1 diabetes mellitus

Renal allotransplantation is the most effective and safest mode of renal replacement therapy in patients with diabetes mellitus (DM),and currently is recognized as method of choice for patients with end-stage renal disease. Due to variety of factors damaging transplantedkidney in patients with DM, issues of long-term survival of the graft constitute a serious problem. Therefore, special attentionshould be directed at correction of rejection risk factors in order to prolong graft survival - and prevent development and progressionof chronic allograft nephropathy.

Beneficial effect of Astragalus membranaceus on estimated glomerular filtration rate in patients with progressive chronic kidney disease

Several types of herbal preparations have been used as supplementary therapies for the treatment of progressive chronic kidney disease (CKD), but the scientific evidence for their use is scarce. The aim of the present study was to determine the effects of Astragalus membranaceus on renal outcome in patients with progressive CKD. The study population consisted of 35 patients with CKD stages 4 and 5 whose estimated glomerular filtration rate (eGFR) decreased over a 3-month period before the start of A membranaceus treatment despite the use of conventional therapy (from 14.6 ± 6.28 mL/min/1.73 m 2 to 11.6 ± 5.24; mean ± SD, p < 0.05). Similarly, the eGFR of 15 patients with CKD stage 4 decreased over the same period despite conventional therapy (from 20.8 ± 4.59 to 16.7 ± 4.17; r = −1.298; p < 0.05), but increased after the initial period of 3 months of supplementary treatment with A membranaceus (to 18.6 ± 5.67; r = 0.973; p < 0.05) and remained at that level at 6 months (17.8 ± 5.60) and 12 months (16.3 ± 5.89). However, in 20 patients with CKD stage 5, the beneficial effect of A membranaceus was limited to the first 3 months only (−3 months: 10.5 ± 2.7, baseline: 8.0 ± 2.75, 3 months: 8.4 ± 2.96, 6 months: 6.8 ± 2.45). A membranaceus had no significant effects on other laboratory parameters. Only seven patients (1 in stage 4 and 6 in stage 5) required dialysis within 12 months of A membranaceus treatment, whose eGFR at baseline was relatively low (7.4 ± 1.06). The results suggest that A membranaceus can maintain stable levels of eGFR and delay the initiation of renal replacement therapy in patients with progressive CKD stage 4. 至今已有數種草藥製劑被應用於進行性慢性腎病(CKD)的補充療法，然而此用途仍缺乏相關的科學理據。本研究旨在探討膜莢黃耆( Astragalus membranaceus )對進行性CKD患者的腎臟效應。研究對象為35位第4或5期CKD患者，即使在常規治療下(不包括 A membranaceus )，其腎絲球過濾率估算值(eGFR)仍在3個月內明顯下降(從14.6 ± 6.28 mL/min/1.73 m 2 至11.6 ± 5.24; mean ± SD, p < 0.05)。其中15人為第4期CKD患者，eGFR於該段期間明顯下降(從20.8 ± 4.59至16.7 ± 4.17; r = −1.298; p < 0.05)，但在膜莢黃耆補充療法開始後3個月回升(至18.6 ± 5.67; r = 0.973; p < 0.05)，並維持穩定於6個月(17.8 ± 5.60)及12個月(16.3 ± 5.89)。另外20位為第5期CKD患者，膜莢黃耆對其效益僅可見於首3個月(−3個月: 10.5 ± 2.7, 基線: 8.0 ± 2.75, 3個月: 8.4 ± 2.96, 6個月: 6.8 ± 2.45)。至於其他實驗室項目，膜莢黃耆並不具明顯效應。在膜莢黃耆的12個月治療期間，僅7人(第4期：1人；第5期：6人)需接受透析治療，其基線eGFR均偏低(7.4 ± 1.06)。因此，對於第4期進行性CKD患者，膜莢黃耆有助維持eGFR於穩定水平，並延遲腎臟替代療法的開始時間.

Timing for initiation of continuous renal replacement therapy in patients with septic shock and acute kidney injury

The optimal timing for initiation of renal replacement therapy (RRT) in septic acute kidney injury (AKI) remains controversial. The aim of this study is to investigate the impact of early versus late initiation of continuous RRT (CRRT), as defined using the simplified RIFLE classification, on organ dysfunction among patients with septic shock and AKI.

Late Initiation of Continuous Veno-Venous Hemofiltration Therapy is Associated with a Lower Survival Rate in Surgical Critically Ill Patients with Postoperative Acute Kidney Injury

There is controversy about the appropriate timing for renal replacement therapy in patients with acute kidney injury (AKI). We are interested in the appropriate timing for initiation of continuous renal replacement therapy in critically ill surgical patients with postoperative acute kidney injury. Seventy-three critically ill surgical patients with postoperative AKI who received continuous renal replacement therapy (CRRT) were enrolled. Indications for CRRT were: 1) AKI with hyperkalemia, 2) metabolic acidosis, 3) pulmonary edema refractory to diuretics, and 4) oliguria with progressive azotemia, especially in unstable hemodynamics. Using RIFLE (Risk, Injury, Failure, Loss, End stage) classification, patients who received CRRT in the “Risk” stage were defined as early group, whereas those in the “Injury/ Failure” stage were labeled as late group. We used continuous veno-venous hemofiltration as CRRT in this series. There were 20 patients in the early group and 53 patients in the late group. The mean ages were 61.5 ± 21.8 years versus 60.8 ± 17.5 years. The mortality rate was 50 per cent versus 84.9 per cent. There were no significant differences in demographic characteristics or type of surgery or physiological scores. Our data show that late initiation of CRRT is associated with a lower survival rate in critically ill surgical patients with postoperative AKI; however, further studies are required.

Population-based incidence, mortality and quality of life in critically ill patients treated with renal replacement therapy: a nationwide retrospective cohort study in finnish intensive care units

IntroductionAcute kidney injury (AKI) increases mortality and morbidity of critically ill patients. Mortality of patients treated with renal replacement therapy (RRT) is high. We aimed to evaluate the nationwide incidence of RRT-treated AKI in Finland, hospital and six-month mortality, and health-related quality of life (HRQoL) of these patients.MethodsWe performed a retrospective cohort study including all general intensive care unit (ICU) admissions in Finland in 2007 through 2008. We identified patients who had received RRT due to AKI (RRT patients) and compared these patients to ICU patients who were not treated with RRT (non-RRT patients). The HRQoL was assessed by the EQ-5D index and visual analogue scale (VAS).ResultsWe analysed the final cohort of 24,904 patients, of whom 1,686 received RRT due to AKI. The incidence of RRT-treated AKI was 6.8% (95% confidence interval (CI) 6.5 to 7.1%) among ≥ 15-year-old general ICU patients, which corresponds to a yearly population-based incidence of 19.2 per 100,000 (95% CI 17.9 to 20.5/100,000). According to RIFLE (Risk, Injury, Failure) classification 26.6% (95% CI 26.0 to 27.2%) of patients had AKI (RIFLE R-F). Hospital and six-month mortality of RRT patients were 35.0% and 49.4%. At six-months, RRT patients perceived their health as good as non-RRT patients by VAS.ConclusionsThe population-based incidence of AKI treated with RRT was 19.2 per 100,000 in Finland and 6.8% of all general ICU patients. The hospital and six-month mortality rates were lower than previously reported for ICU-treated RRT patients.

Snake Bite Induced Acute Renal Failure: A Study of Clinical Profile and Predictors of Poor Outcome

Background : Acute renal failure is an important cause of morbidity and mortality in snake bite patients, especially in tropical countries. This study was aimed to describe clinical profile and to identify predictors of poor outcome in snake bite induced acute renal failure. Methods: This was a retrospective observational study, conducted in a tertiary care hospital, 57 patients of snake bite induced ARF, who required dialysis were included. Clinical history taking, physical examination and laboratory evaluation was done. All patients received standard treatment including Antisnake venom. Patients received peritoneal or hemodialysis depending on availability of resources. The Pearson Chi-Square Test was used to analyze parametric variables . Results: Prevalence of ARF in snake bite was 20.48%.Common clinical manifestations were local cellulitis (100%), oliguria (84.2%), edema (33.3%), hematuria (29.8%), altered sensorium (26.3%) and bleeding manifestations (22.8%). Common laboratory findings were albuminuria (100%), anaemia (54.3%); leucocytosis (61.4%); thrombocytopenia (42.1%); coagulopathy (36.8%); metabolic acidosis (31.5%). Conclusions: Snake bite induced ARF has mortality of 15.5%. The factors associated with mortality were presence of coagulopathy and uremic encephalopathy. Though this study is not designed to compare hemodialysis and peritoneal dialysis, the better outcome in hemodialysis group suggests the need to compare the two modalities of renal replacement therapy in patients with snake bite induced acute renal failure. doi:10.4021/wjnu13w

Snake bite-induced acute renal failure: A study of clinical profile and predictors of poor outcome

Aims: Acute renal failure is an important cause of morbidity and mortality in snake bite patients, especially in tropical countries. This study was aimed to describe clinical profile and to identify predictors of poor outcome in snake bite-induced acute renal failure. Settings and Design: This was a retrospective observational study, conducted in a tertiary care hospital. Materials and Methods: 57 patients of snake bite-induced ARF, who required dialysis, were included. Clinical history taking, physical examination, and laboratory evaluation was done. All patients received standard treatment including anti-snake venom. Patients received peritoneal or hemodialysis depending on availability of resources. The Pearson Chi-Square test was used to analyze parametric variables. Results: Prevalence of ARF in snake bite was 20.48%. Common clinical manifestations were local cellulitis (100%), oliguria (84.2%), edema (33.3%), hematuria (29.8%), altered sensorium (26.3%), and bleeding manifestations (22.8%). Common laboratory findings were albuminuria (100%), anemia (54.3%); leucocytosis (61.4%); thrombocytopenia (42.1%); coagulopathy (36.8%); metabolic acidosis (31.5%). Conclusions: Snake bite-induced ARF has mortality of 15.5%. The factors associated with mortality were presence of coagulopathy and uremic encephalopathy. Though this study is not designed to compare hemodialysis and peritoneal dialysis, the better outcome in hemodialysis group suggests the need to compare the 2 modalities of renal replacement therapy in patients with snake bite-induced acute renal failure.

The third and fourth renal transplant; Technically challenging, but still a valid option

At present, first and second kidney transplantation have established surgical techniques with few variations between surgeons. They also are considered the best renal replacement therapy for patients with end stage renal disease. Both offer better quality of life and longer survival compared to dialysis. However the third and fourth transplants are significantly more complex. Patients are often highly sensitized, comorbid with limited surgical options due to the previous operations, immunosuppression and long periods on dialysis. There is an incorrect belief that third and fourth retransplantation will not offer any advantage to this cohort of patients and considered to be poor utilization of the limited supply of organs. Recent work demonstrated that third and fourth transplantation offers a survival advantage however it slightly inferior to first and second transplantation, but still there is no established technique. In spite of the surgical challenge, the main cause of graft loss in this cohort of patient is immune mediated rather than the surgical complications. In this review article, we describe various techniques used in transplanting these surgically, immunologically and medically challenging patients demonstrating the effect of surgical complications on the outcome.

AGEs and Cardiovascular Diseases in Patients With End-Stage Renal Diseases

Cardiovascular disease is the major cause of death in patients with renal insufficiency, accounting for 50% of all deaths in renal replacement therapy patients. Mortality from cardiovascular diseases in these patients is approximately 9% per year, which is about 30 times the risk in the general population. So far, intensive interventions to the general risk factors, such as high levels of low-density lipoprotein -cholesterol or C-reactive protein, have not been successful in improving their cardiovascular outcomes, suggesting that the beneficial effect of risk reduction may be overwhelmed by accumulated risk memorized by long-term exposure to oxidative stress during the progression of renal failure. This irreversible memory effect may be mediated by advanced glycation end products (AGEs), the generation of which has been implicated to be deeply associated with increased oxidative stress. To examine whether circulating AGEs predict future cardiovascular events, a cohort containing 386 (243 male, 142 female) hemodialysis patients was set up. The patients were examined for plasma pentosidine at registration (December 2005) and were followed until March 2010. Patients with high tertile for plasma pentosidine exhibited significantly higher risk for cardiovascular events (hazard risk: 1.74, 95% confidence interval: 1.11 to 2.74, P = .017). Comparisons of the risk of high plasma pentosidine in key subgroups showed that the risk of the high tertile was more prominent in patients with low serum albumin levels. Thus, AGE levels could represent accumulated oxidative stress during the progression of CKD, and their measurements would be useful for stratification of the cardiovascular risks in patients with ESRD.

The STARRT trial: a cost comparison of optimal vs sub-optimal initiation of dialysis in Canada

Background:Sub-optimal transitioning of patients from chronic kidney disease (CKD) to end stage renal disease (ESRD) may result in poor clinical outcomes and increased healthcare costs. The objectives of this study were to estimate the average total cost per patient who requires initiation of renal replacement therapy (RRT) stratified by status at initiation; optimal (RRT initiation as an outpatient with an arterio-venous [AV] Fistula, Graft or Peritoneal Dialysis [PD] catheter), and sub-optimal (RRT initiation as an inpatient and/or via central venous catheter [CVC]).Methods:Data from the Study To Assess Renal Replacement Therapy (STARRT), a Canadian, multi-centre, 6 month retrolective study (n = 339), were used for this analysis. Unit costs for resources were obtained from participating hospitals, the literature, and/or standard costing sources. The analysis was performed from the perspective of healthcare payors and reported in 2011 Canadian Dollars (CAD). A propensity score technique was applied to control for potential confounders between the two groups.Results:Two hundred of the eligible patients for analysis (61.9%) were sub-optimally and 123 (38.1%) were optimally prepared. For this analysis, 106 “matched” pairs were used. The average total cost per patient was estimated to be $63,225 (with a 95% CI ranging from $58,663–$67,958) for the sub-optimally initiated patients, and $39,260 (with a 95% CI ranging from $35,683–$43,007) for the optimally initiated patients (p < 0.001).Limitations:Costs were calculated utilizing a conservative approach, using the cheapest available prices for medications and other resources. Assumptions had to be made for the costing of dialyses.Conclusion:The results of this study indicate, after adjusting for potential confounders, that optimally initiated patients for RRT have significantly lower healthcare-associated costs compared to sub-optimally initiated patients.

Long‐term outcome after acute renal replacement therapy: a narrative review

Acute kidney injury (AKI) necessitating renal replacement therapy (RRT) is associated with high short-term mortality, relatively little however is known of the long-term outcome in these patients. This narrative review describes renal recovery, long-term mortality, and quality of life in RRT patients with acute kidney injury. A literature search using the PubMed search engine from the year 2000 to present with the MeSH terms 1) acute kidney injury, renal replacement therapy, prognosis, and 2) acute kidney injury, quality of life, prognosis, was performed, including studies addressing long-term outcome (over 60 days) in adults with AKI on RRT. According to inclusion criteria, twenty two studies were eligible. Outcome varied depending on AKI aetiology, setting, co-morbidity and pre-morbid renal function. Five-year-survival was between 15% and 35%, with dialysis dependence in less than 10% of survivors. Renal recovery, even if incomplete occurred during the first year. Quality of life assessment amongst survivors indicated moderate physical impairment and reduced mental health scores. A majority of patients returned to employment and self-sustainability and reported acceptable to good quality of life. Over 90% of patients indicated that they would undergo the same treatment again. Early initiation of treatment and fine-tuning of the RRT technique may improve outcome. Consensus regarding AKI definitions, renal function measurement and standardised follow-up regimens are required. Further long-term studies are needed.

Outcomes of rationing dialysis therapy in biopsy-proven end-stage renal disease in South Africa

Due to poverty, many countries of sub-Saharan Africa suffer a severe burden of end-stage renal disease (ESRD), the cause of which is often unidentified. We sought to identify biopsy-proven causes of ESRD in Cape Town, South Africa, and to determine the outcome of these patients. Records of biopsies reported as ESRD over a 10-year period were selected for analysis. The demographic, clinical and biochemical characteristics of the patients at the time of biopsy were documented. The decision of the committee that assesses the eligibility of patients for long-term renal replacement therapy (RRT) was documented, and if a patient was not accepted the reasons for the rejection were noted. Chronic glomerulonephritis (CGN) was the most frequent cause of ESRD (31.2%); human immunodeficiency virus-associated nephropathy (HIVAN) accounted for 12.5% of ESRD cases. Sixty-six patients (45.8%) were never reviewed by the assessment committee for placement in the dialysis program. Of the remaining 78 patients (54.2%) reviewed for RRT, only 48/78 (61.5%) were selected. A higher frequency of patients with HIVAN were not accepted for RRT (17.7%) than patients with HIVAN who were accepted (2.1%) (p=0.008). Social factors such as lack of housing, alcohol abuse, illicit drug abuse, lack of transportation and lack of family/social support accounted for 56.7% of patients not being accepted for RRT. There needs to be a development of programs amongst Africans to provide effective solutions that tackle the burden of ESRD, especially related to the increasing prevalence of HIVAN.

Quality of life of patients in renal replacement therapy in Brazil: comparison of treatment modalities

This study aimed to analyze and compare the quality of life of renal replacement therapy patients undergoing hemodialysis, peritoneal dialysis and those with renal transplantation in Brazil. In addition, we aimed to verify factors associated with patients' quality of life and the relationship between quality of life and treatment modality, socioeconomic and demographic conditions as well as aspects related to the disease and health services. A representative sample of the dialysis units and transplant centers was obtained. Structured questionnaires were used to interview 3,036 patients in one of three treatment modalities: hemodialysis, peritoneal dialysis and renal transplant. Information was collected about socioeconomic and demographic characteristics and quality of life measures. There were significant differences between renal transplants and both forms of dialysis for all dimensions of the SF-36. Hemodialysis patients showed better results in the dimensions of functional capacity, physical aspects and social aspects, compared to peritoneal dialysis patients. Renal transplant patients had the best mean score in the physical component of quality of life. There were no significant differences among treatment groups regarding the mental component of quality of life. The physical and mental components were associated with comorbidities and age; however, older patients had better mental quality of life but worse physical quality of life. Patients in a higher socioeconomic class and patients that were not hospitalized also reported better quality of life. Unmarried and male patients presented better physical quality of life. The dialysis units and transplant centers influenced the patients' quality of life. Renal transplant patients have the best quality of life of the three treatment modalities. It is necessary to increase access to renal transplants.