Renal Replacement Therapy In England Research Articles

The UK Renal Registry: making patient data matter.

British Journal of Hospital MedicineVol. 79, No. 5 EditorialThe UK Renal Registry: making patient data matterKatharine M Evans, Rhodri Pyart, Retha Steenkamp, Fergus J CaskeyKatharine M EvansSearch for more papers by this author, Rhodri PyartSearch for more papers by this author, Retha SteenkampSearch for more papers by this author, Fergus J CaskeySearch for more papers by this authorKatharine M Evans; Rhodri Pyart; Retha Steenkamp; Fergus J CaskeyPublished Online:4 May 2018https://doi.org/10.12968/hmed.2018.79.5.246AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Birnie K, Caskey F, Ben-Shlomo Y, Sterne JA, Gilg J, Nitsch D, Tomson C. 2017. Erythropoiesis-stimulating agent dosing, haemoglobin and ferritin levels in UK haemodialysis patients 2005–13. Nephrol Dial Transplant. 32(4):692–698.https://doi.org/10.1093/ndt/gfw043 Medline, Google ScholarByrne C, Caskey F, Castledine C et al.. 2017. UK Renal Registry 19th Annual Report 2016. Nephron. 137 (suppl 1) Google ScholarGallagher H, Methven S, Casula A et al.. 2017. A programme to spread eGFR graph surveillance for the early identification, support and treatment of people with progressive chronic kidney disease (ASSIST-CKD): protocol for the stepped wedge implementation and evaluation of an intervention to reduce late presentation for renal replacement therapy. BMC Nephrol. 18(1):131. https://doi.org/https://doi.org/10.1186/s12882-017-0522-9 Medline, Google ScholarJudge A, Caskey FJ, Welton NJ, Ansell D, Tomson CRV, Roderick PJ, Ben-Shlomo Y. 2012. Inequalities in rates of renal replacement therapy in England: does it matter who you are or where you live? Nephrol Dial Transplant. 27(4):1598–1607. https://doi.org/https://doi.org/10.1093/ndt/gfr466 Crossref, Medline, Google ScholarUdayaraj U, Ben-Shlomo Y, Roderick P et al.. 2012. Social deprivation, ethnicity, and uptake of living kidney donor transplantation in the United Kingdom. Transplantation. 93(6):610–616. https://doi.org/https://doi.org/10.1097/TP.0b013e318245593f Medline, Google Scholar FiguresReferencesRelatedDetails 2 May 2018Volume 79Issue 5ISSN (print): 1750-8460ISSN (online): 1759-7390 Metrics History Published online 4 May 2018 Published in print 2 May 2018 Information© MA Healthcare LimitedPDF download

Predicting hospital costs for patients receiving renal replacement therapy to inform an economic evaluation.

To develop a model to predict annual hospital costs for patients with established renal failure, taking into account the effect of patient and treatment characteristics of potential relevance for conducting an economic evaluation, such as age, comorbidities and time on treatment. The analysis focuses on factors leading to variations in inpatient and outpatient costs and excludes fixed costs associated with dialysis, transplant surgery and high cost drugs. Annual costs of inpatient and outpatient hospital episodes for patients starting renal replacement therapy in England were obtained from a large retrospective dataset. Multiple imputation was performed to estimate missing costs due to administrative censoring. Two-part models were developed using logistic regression to first predict the probability of incurring any hospital costs before fitting generalised linear models to estimate the level of cost in patients with positive costs. Separate models were developed to predict inpatient and outpatient costs for each treatment modality. Data on hospital costs were available for 15,869 incident dialysis patients and 4511 incident transplant patients. The two-part models showed a decreasing trend in costs with increasing number of years on treatment, with the exception of dialysis outpatient costs. Age did not have a consistent effect on hospital costs; however, comorbidities such as diabetes and peripheral vascular disease were strong predictors of higher hospital costs in all four models. Analysis of patient-level data can result in a deeper understanding of factors associated with variations in hospital costs and can improve the accuracy with which costs are estimated in the context of economic evaluations.

Variation in centre-specific survival in patients starting renal replacement therapy in England is explained by enhanced comorbidity information from hospitalization data

Unadjusted survival on renal replacement therapy (RRT) varies widely from centre to centre in England. Until now, missing data on case mix have made it impossible to determine whether this variation reflects genuine differences in the quality of care. Data linkage has the capacity to reduce missing data. Modelling of survival using Cox proportional hazards of data returned to the UK Renal Registry on patients starting RRT for established renal failure in England. Data on ethnicity, socioeconomic status and comorbidity were obtained by linkage to the Hospital Episode Statistics database, using data from hospitalizations prior to starting RRT. Patients with missing data were reduced from 61 to 4%. The prevalence of comorbid conditions was remarkably similar across centres. When centre-specific survival was compared after adjustment solely for age, survival was below the 95% limit for 6 of 46 centres. The addition of variables into the multivariable model altered the number of centres that appeared to be 'outliers' with worse than expected survival as follows: ethnic origin four outliers, socioeconomic status eight outliers and year of the start of RRT four outliers. The addition of a combination of 16 comorbid conditions present at the start of RRT reduced the number of centres with worse than expected survival to one. Linked data between a national registry and hospital admission dramatically reduced missing data, and allowed us to show that nearly all the variation between English renal centres in 3-year survival on RRT was explained by demographic factors and by comorbidity.

Inequalities in rates of renal replacement therapy in England: does it matter who you are or where you live?

Introduction. This study explores the geographical variation in renal replacement therapy (RRT) incidence and prevalence after adjusting for general population socio-demographics, renal unit treatment patterns and travel times. The UK Renal Registry provided data on all patients in England commencing RRT in 2007 and receiving RRT on 31 December 2007. Multilevel Poisson regression models were constructed separately for incidence and prevalence. Geographical Information Systems software enabled estimation of road travel times and renal unit catchment areas. Small area estimates of RRT prevalence were produced for all 354 local authority districts. Adjusted RRT incidence rates were 1.4 (95% confidence interval 1.2-1.6) times higher in the most deprived areas and 1.7 (1.5-2.0) and 1.5 (1.3-1.7) times higher in areas with most Black and South Asian inhabitants (10+%), respectively. The proportion of a centre's patients on haemodialysis or transplanted were positively associated with RRT incidence (not prevalence); numbers of satellite units were negatively associated with RRT incidence (not prevalence). While only 3% of patients lived >30 min from a dialysis unit, there was an effect of travel time on RRT rates; individuals living 45+ min from a dialysis unit were 20% less likely to commence or receive RRT than those living within 15 min (Ptrend=0.36 and Ptrend<0.001, respectively). A 4-fold variation in adjusted local authority district RRT prevalence rates could not be explained. Expansion of renal unit facilities in England has reduced travel times in most areas though the possibility of inequitable geographic access to RRT persists.

Patterns and effects of missing comorbidity data for patients starting renal replacement therapy in England, Wales and Northern Ireland

Renal Registries play a key role in assessing quality of care and outcomes of renal replacement therapy and comparisons of outcomes between groups should adjust for differences in comorbidities. This study aimed to describe patterns of missing comorbidity data and differences in survival between patients with comorbidity data returned and those with missing comorbidity data. Trends in comorbidity data returns by year (1998-2006) and within centres were examined using descriptive statistics. Survival of patients was described using Kaplan-Meier graphs (log-rank tests) and hazard ratios were calculated using Cox proportional hazard models. Last follow-up was at 31 December 2007. A range of sensitivity analyses were carried out, including multiple imputation. Among 34,059 patients, there were 62% who had no comorbidity data. The completeness of comorbidity data increased markedly from 17% in 1998 to 47% in 2003, but had fallen back to 37% by the year 2006. Those with a missing comorbidity generally do considerably worse than those without the comorbidity and in most cases more closely follow the survival curve of those with the comorbidity. Multiple imputation analysis suggested that those with missing information on comorbidity have higher prevalence of comorbidity than seen in those with available data. Treating missing comorbidity entries as indication of absent comorbidity (i.e. a tick only if yes policy) would lead to an attenuation of the effect of comorbidity on survival. Missing data lead to difficulties in performing between centre comparisons. A 'tick if present policy' in comorbidity data collection should be discouraged. Much more work is needed to fully understand why levels of missing comorbidity data are so high and to identify strategies to improve recording.

Socio-economic status, ethnicity and geographical variations in acceptance rates for renal replacement therapy in England and Wales: an ecological study

BackgroundIt is not known to what extent the reported regional variations in renal replacement therapy (RRT) acceptance rates in England and Wales are due to differences in the socio-demographic characteristics...

Survival of patients from South Asian and Black populations starting renal replacement therapy in England and Wales

Background. South Asian and Black ethnic minorities in the UK have higher rates of acceptance onto renal replacement therapy (RRT) than Caucasians. Registry studies in the USA and Canada show better survival; there are few data in the UK.Methods. Renal Association UK Renal Registry data were used to compare the characteristics and survival of patients starting RRT from both groups with those of Caucasians, using incident cases accepted between 1997 and 2006. Survival was analysed by multivariate Cox's proportional hazards regression split by haemodialysis and peritoneal dialysis (PD) due to non-proportionality, and without censoring at transplantation.Results. A total of 2495 (8.2%) were South Asian and 1218 (4.0%) were Black. They were younger and had more diabetic nephropathy. The age-adjusted prevalence of vascular co-morbidity was higher in South Asians and lower in Blacks; other co-morbidities were generally common in Caucasians. Late referral did not differ. They were less likely to receive a transplant or to start PD. South Asians and Blacks had significantly better survival than Caucasians both from RRT start to Day 90 and after Day 90, and for those on HD or PD at Day 90. Fully adjusted hazard ratios after Day 90 on haemodialysis were 0.70 (0.55–0.89) for South Asians and 0.56 (0.41–0.75) for Blacks.Conclusion. South Asian and Black minorities have better survival on dialysis. An understanding of the mechanisms may provide general insights for all patients on RRT.

Blood Pressure and Mortality Risk on Peritoneal Dialysis

The association of baseline blood pressure (BP) and mortality in incident peritoneal dialysis patients has not been adequately studied. Cohort study. 2,770 patients on PD therapy at 180 days from start of renal replacement therapy in England and Wales between 1997 and 2004. Systolic BP (SBP), diastolic BP (DBP), mean arterial pressure (MAP), and pulse pressure (PP) measured in the first 6 months of renal replacement therapy and other baseline demographic and laboratory variables. All-cause mortality was studied using time-stratified Cox regression models (to account for nonproportionality) dividing follow-up time into 4 intervals: year 1 (days 180 to 365), years 2 to 3, years 4 to 5, and years 6+. Interactions between BP components and transplant waitlist and diabetes status were explored. Median follow-up was 3.7 years (range, 0.1 to 9.9 years), and 1,104 deaths were observed. In fully adjusted analyses, greater SBP, DBP, MAP, and PP were associated with decreased mortality in the first year, but greater SBP and PP were associated with increased late mortality (in years 6+). However, in the subgroup of patients placed on the transplant waitlist within 6 months of starting renal replacement therapy, greater SBP, DBP, MAP, and PP were not associated with decreased mortality in the first year. Exclusion of 3,086 patients because of missing BP data. No data were available for cardiac function or antihypertensive medication. Although greater SBP, DBP, MAP, and PP appear protective against early mortality in the overall cohort, this effect is not seen in patients registered on the national transplant waiting list within 6 months of starting renal replacement therapy.

New adult patients starting renal replacement therapy in the UK in 2005 (Chapter 3)

In 2005, the acceptance rate for renal replacement therapy (RRT) in adults in the UK was 108 per million population (pmp). This was derived from complete data for adults in the UK, as data were obtained separately from the five English renal units not currently returning to the Registry. In addition, 87 children started RRT (see Chapter 13) giving a total incidence of 110 pmp. From 2001 to 2005 there has been an 7.3% rise in the acceptance numbers in those 42 renal units with full reporting throughout that period. In the UK, for adults in 2005, the crude acceptance rates in Local Authorities (LA) varied from 0 (in two very small LA areas in Scotland and Northern Ireland) to 271 pmp; the standardized rate ratios for acceptance varied from 0 to 2.76. Excluding the two areas with null returns, 20 areas had significantly low ratios, all of them in England. Thirty had significantly high ratios, seven in Northern Ireland, four in Scotland, three in Wales and seven in London. Over the period 2001-2005, 25 areas had a significantly low standardized acceptance rate; 24 in England and one in Scotland. All except one of these had ethnic minority populations of <10%. Thirty-seven had high standardized acceptance rates, seven in Scotland where ethnicity data were not available, 14 from areas with ethnic minority populations in excess of 10%, and 12 were in Wales or the Southwest of England. The median age of patients starting RRT in England has increased from 63.8 years in 1998 to 65.2 years in 2005. The median age of incident non-White patients is significantly lower at 56.8 years. In England, the acceptance rate is highest in the 75-79 age band at 408 pmp, as in Scotland at 580 pmp; in Wales the peak is in the 80-84 age band at 525 pmp, as in Northern Ireland with a rate of 825 pmp. Diabetic renal disease (20%) remains the most common specific primary renal disease. There was a significant positive correlation between the percentage of incident RRT patients with diabetic renal disease and the percentage of non-Whites in the incident cohort. Haemodialysis (HD) was the first modality of RRT in 76% of patients, peritoneal dialysis (PD) in 21% and pre-emptive transplant in 3%. In 1998, the proportion whose first modality was HD was 58% and this continues to increase. By day 90, 8% had died, a further 1% had stopped treatment or been transferred out leaving 91% of the original cohort on RRT. Of these, 71% were on HD, 26% on PD and 3% had received a transplant. Data on first referral to a nephrologist were available from 22 centres for the period 2000-2005 (for a total of 5611 patients and 59 centre-years). In 2005, the mean percentage of patients referred late (<90 days before dialysis initiation) was 30% (centre range 13-48%). This was similar to the value in 2000. Patients referred late were older, a higher proportion of them were male, a lower proportion non-White, and a lower proportion with no recorded comorbidity. Patients with polycystic kidney disease and diabetic nephropathy tended to be referred early compared with the whole incident cohort and those with uncertain aetiology and no recorded diagnosis referred late. Estimated GFR (eGFR) at the start of RRT appears to be higher in older than younger patients. eGFR is significantly lower in those referred late compared with those referred earlier and this is especially marked in the older patients. The geometric mean eGFR of all patients starting RRT rose from 6 in 1997 to above 7.5 in 2003, since when it has remained stable.

Patients with diabetic nephropathy on renal replacement therapy in England and Wales

The incidence of patients with diabetic nephropathy (DN) who start renal replacement therapy (RRT) is increasing. To describe the characteristics and survival of patients with DN starting RRT in the UK. Retrospective cohort study. We analysed data for incident patients on RRT in centres participating in the Renal Association UK Renal Registry (UKRR), 1997 -2004, comparing DN vs. non-DN patients with regard to survival, social deprivation, ethnicity, gender, and age, using Cox regression models. DN was the most common renal disease (19%) in the 20 532 patients starting RRT. The majority of patients with DN (77%) were Caucasian. Within the Caucasian population, DN patients were more likely to be from a socially deprived area (p < 0.0001). About 20% were referred <3 months before starting RRT. The difference in crude survival was greatest in younger patients (5-year survival was 56% (DN) vs. 85% (non-DN) in patients aged 18-54 years, and 17% (DN) vs. 28% (non-DN) in patients aged >or=65 years). Despite adjusting for gender, age, treatment modality, social deprivation, referral and co-morbidities, the long-term prognosis for DN patients aged 18-54 years was worse (adjusted hazard ratio 2.13, 95%CI 1.23-3.67) than for older age groups. Patients with DN starting RRT are more likely to come from socially deprived areas. Relative risk of death is greatest in working-age DN patients and is not fully explained by recorded co-morbidity. This emphasizes the need for focused diabetes care in poorer areas, and assessment of quality of care of diabetic patients on RRT.

Social deprivation and survival on renal replacement therapy in England and Wales

This study examines the association between social deprivation and patient characteristics and outcomes in a nationally representative cohort of incident renal replacement therapy (RRT) patients. All Caucasian patients reported to the UK Renal Registry between 1997 and 2004 by centers in England and Wales with high data completeness were included. Social deprivation was assessed using the Townsend index. Socially deprived patients were more likely to be referred late. They were less likely to receive peritoneal dialysis (25.1 vs 34.8% on day 1, P trend <0.0001) or a renal transplant (5.3 vs 12.4% at 1 year, P trend <0.0001), and were less likely to attain UK Renal Association standards for hemoglobin and phosphate at 1 year. Crude survival decreased significantly with increasing deprivation for patients under the age of 65 years, but not for those aged 65 years and above (likelihood ratio for age-social deprivation interaction P<0.0001). Social deprivation was significantly associated with poorer survival after adjustment for age, gender, and cause of renal failure. After adjusting for baseline co-morbidity, social deprivation was no longer associated with poorer survival. Baseline differences in co-morbidity seem to explain poorer crude survival in incident Caucasian RRT patients from socially deprived areas in England and Wales. Differences also exist in some processes of care and intermediate outcomes, which may be amenable to intervention.

Simulation model of renal replacement therapy: predicting future demand in England.

The demand for renal replacement therapy (RRT) in England has risen steadily, although from a lower base than many other developed countries. Predicting the future demand for RRT and the impact of factors such as the acceptance rate, transplant supply and patient survival, is required in order to inform the planning of such services. A discrete event simulation model estimates the future demand for RRT in England in 2010 for a range of scenarios. The model uses current prevalence and current and projected future acceptance rates, survival rates and the transitions between modalities to predict future patient numbers. National population and mortality data, published literature and data from the UK Renal Registry and UK Transplant, are used to estimate unmet need for RRT, the impact of changing demography and incidence of Type 2 diabetes, patient haemodialysis (HD) survival and transplant supply. By 2010 the predicted prevalence will have increased from about 30,000 in 2000 to between 42 and 51,000 (900-1000 p.m.p.), an average annual growth of 4.5-6%. Changing transplant supply has a small effect on overall numbers but changes the proportion of patients with functioning graft by up to 8%. Even with an optimistic increase in transplant supply (11% p.a. for 5 years), numbers on HD will continue to rise substantially, especially in the elderly. The factors most influencing future patient numbers are the acceptance rate and dialysis survival. This model predicts a substantial growth in the RRT population to 2010 to a rate approaching 1000 p.m.p., particularly in the elderly and those on HD, with a steady state not being reached for at least 25 years.

What determines geographical variation in rates of acceptance onto renal replacement therapy in England?

To determine the independent effects of need and supply factors on the known geographical variation in acceptance rates onto renal replacement therapy (RRT) in England. Data were obtained from all renal units in England on the characteristics of all cases aged 16 years and over, resident in England, who were accepted onto RRT in 1991 and 1992. Of these, 5715 (94.5%) had a valid postcode that could be matched to a census ward. Multilevel modelling using Poisson regression was used. The number of acceptances in each census ward within age bands 16-34, 35-64 and 65+ was the dependent variable. Independent effects modelled were: (1) individual factors (age, sex); (2) census ward need factors--ethnicity (expressed as the percentage of the ward population that was Asian or African-Caribbean), socio-economic deprivation--and supply factors--'access' to the nearest renal unit using crowfly and road travel time and distance, and services available to each ward expressed as number of haemodialysis stations per 100,000 catchment population of the nearest renal unit; (3) district health authority level effects. Age was a major determinant of acceptance, with a 7-fold higher rate in males aged over 64 years compared with younger men. Acceptance rates were lower in females, with a negative age-sex interaction in females aged over 64 years. The percentage of both Asian and African-Caribbean populations per ward was a highly significant positive determinant. Deprivation was also a significant determinant, best represented by a customised index. There was an inverse relation of acceptance with distance, especially road travel time. Other supply side variables had a significant effect though there was no independent district effect. There was some variation in the strength of these relationships by type of area (Greater London, urban and non-urban). Need and supply factors influence service use as expressed as acceptance onto RRT. Pressure to expand RRT services needs to be aimed at areas with large minority ethnic populations and those living far from existing units.

Geographical aspects of the uptake of renal replacement therapy in England

The National Renal Review provides a complete picture of new patients treated by renal replacement therapy (RRT) in England in 1991-92. RRT is a lifesaving treatment for patients with endstage renal failure. This paper describes an analysis of the review data using multilevel modelling to assess the effects of age, sex, ethnicity, deprivation, access and supply factors on acceptance onto RRT. In particular, we focus on the additional effect of deprivation, access and supply when the basic population factors are taken into account. After a summary of the results of national modelling, a series of models for Greater London, Metropolitan and non-Metropolitan areas are presented, which examine the variations in these factors by area type.

Geographical aspects of the uptake of renal replacement therapy in England

Geographical aspects of the uptake of renal replacement therapy in England

Predicting the future demand for renal replacement therapy in England using simulation modelling.

The purpose of the study was to estimate the future demand for renal replacement therapy in England. Simulation modelling was used to estimate the future demand, under varying assumptions, about the growth in the acceptance rate for renal replacement therapy, patient and treatment survival, and the availability of kidney transplants. Data were obtained from the National Renal Review, the European Dialysis and Transplant Registry, and the United Kingdom Transplant Support Services Authority. They were analysed to provide transfer and survival data on patients treated for end-stage renal failure in England and in four exemplary district health authorities. The simulation runs provided estimates of numbers of patients being treated by dialysis and transplantation over the next 15 years. The results indicated that the number under treatment was predicted to rise by between 50 and 100% over the next 15 years, with a disproportionate increase in dialysis of up to 150%. There will be more 'high-risk elderly' people under treatment, particularly amongst the dialysis patients. The growth in numbers will vary between districts depending on their level of need and current service position. There will be increasing numbers of patients, particularly elderly patients with associated comorbidity, receiving treatment. Given the shortage of kidneys for transplantation, the demand will fall on haemodialysis and continuous ambulatory peritoneal dialysis facilities. Purchasers are thus faced with steeply rising costs for this patient group, especially in areas of high need, whilst needing to find improvements in their quality of care.