Late presentation of patients with end-stage renal disease for renal replacement therapy--is it always avoidable?

BACKGROUND: Twenty-five to 30% of new renal replacement therapy (RRT) patients present late to renal services. The proportion in whom this is avoidable, and whether awareness of chronic kidney disease (CKD) has reduced its incidence is not known. METHODS: Adult patients starting RRT (2003-2008) in a single unit were grouped according to the time interval between first presentation to the unit and start of RRT: <90 days (late presenters); 90-364 days; ≥ 365 days. 'Late presenters' were classified as follows: acute kidney injury--patients who had acute but irreversible renal failure; 'avoidable' late referrals, if they had known pre-existing CKD and 'unavoidable' late referrals, if they had unpredictable rapid progression of their CKD or had no prior contact with health care. Mortality risk associated with late presentation was explored using multivariable Cox regression. RESULTS: Late presentation was common (24.3%) but late referrals accounted for only 7.4% and 3.9% were avoidable. The incidence of late referrals decreased from 9.2% in 2003-2005 to 5.5% in 2006-2008 (trend P = 0.07). Late presentation was associated with increased mortality after adjusting for comorbidity, transplantation and permanent vascular access, and the majority of late presenters died due to malignancy or withdrawal of RRT. CONCLUSIONS: The lower incidence of late referrals and the falling trend could be due to implementation of automated estimated glomerular filtration rate reporting and the increased awareness of CKD in primary care. Future prospective studies are needed to examine the extent to which frailty contributes to this mortality risk.

Blood pressure and mortality risk on peritoneal dialysis.

BACKGROUND: The association of baseline blood pressure (BP) and mortality in incident peritoneal dialysis patients has not been adequately studied. STUDY DESIGN: Cohort study. SETTING & PARTICIPANTS: 2,770 patients on PD therapy at 180 days from start of renal replacement therapy in England and Wales between 1997 and 2004. PREDICTORS: 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. OUTCOMES: 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. RESULTS: 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. LIMITATIONS: Exclusion of 3,086 patients because of missing BP data. No data were available for cardiac function or antihypertensive medication. CONCLUSIONS: 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.

HIV-related admissions to a district general hospital in the U.K.: a single centre study.

This study evaluates the patient and disease characteristics, potential cost implications and short-term outcomes of 64 adult patients admitted with HIV-related illnesses. The majority (65.6%) were black Africans and 75% were immigrants to the U.K. Of the 64 patients, 61% were unaware of their HIV status at admission; 50% had CD4 count <50 cells/microl and 48% had viral load >10(5) copies/ml. Thirty-eight patients had AIDS and this accounted for 66% of the total 897 inpatient days (equivalent to 16.5-30.2 patient years of highly active antiretroviral therapy (HAART), depending on the type of HAART regimen used). Fifteen (23.8%) died in hospital, and of these 11 had AIDS and a CD4 count <200 cells/microl. Immigrants from countries of high prevalence accounted for the majority of the inpatient HIV caseload. They presented late and had high in-hospital mortality. Screening programmes to allow early diagnosis and treatment should be adapted to reach migrant populations.

Chronic kidney disease in kidney transplant recipients-is it different from chronic native kidney disease?

BACKGROUND: The rate of change in estimated glomerular filtration rate (ΔeGFR), factors influencing ΔeGFR, and its association with mortality has not been well studied in renal transplant recipients. METHODS.: Adult kidney-only recipients between January 2001 and December 2004, with surviving grafts 1 year after transplantation, from England and Wales were followed up till 31 December 2006, graft failure or death. The four variable modification of diet in renal disease equation was used to estimate GFR and ΔeGFR assessed using linear least square regression. ΔeGFR of -1 mL/min/1.73m per year and above was considered to be stable or improving function. Linear regression and Cox regression analyses were used to examine factors influencing ΔeGFR and its association with mortality, respectively. RESULTS: Of the 2, 927 patients included, ΔeGFR was -1.3±6.0 mL/min/1.73 m per year and eGFR remained stable or improved in the majority (54.8%). Baseline graft function at 1 year or live donor status did not influence ΔeGFR. Male donor to female recipient transplantation, younger recipients, diabetes, white race, and human leukocyte antigen mismatch were associated with faster decline in eGFR. ΔeGFR was not associated with mortality when censored for graft failure. CONCLUSIONS: Majority of renal transplant recipients experienced stable or improved graft function. Specific donor and recipient characteristics influenced the rate of decline in eGFR. The lack of association of ΔeGFR with mortality, the stability of eGFR in the majority, and influence of donor characteristics on ΔeGFR suggest caution when applying prognosis knowledge from the native kidney disease to the kidney transplant population.

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

BACKGROUND: It 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 of the population. METHODS: The authors calculated age-gender indirectly standardised RRT rates in 2007 for Primary Care Trusts (PCT)/Local Health Boards (LHB) in England and Wales and Government Office Regions (GOR) in England. Multivariable Poisson regression was used to examine the regional variations in the age-gender standardised RRT rates before and after adjustment for area deprivation (Townsend index) and the proportion of non-white people living in an area. RESULTS: Increasing deprivation of PCT/LHB was associated with higher RRT acceptance rates. RRT rates were higher in PCTs with a greater proportion of non-white people in England (correlation coefficient 0.60, p<0.001) but not in Wales. There were variations in the age-gender standardised RRT rates between PCT/LHBs in England and Wales. Adjusting for deprivation and the proportion of non-white people attenuated the high RRT rate ratio observed in London and West Midlands, but the RRT acceptance rate ratio (95% CI) remained higher in Wales 1.38 (1.22 to 1.57) and lower in North West England 0.82 (0.74 to 0.93) and Yorkshire and Humberside 0.86 (0.77 to 0.98). CONCLUSIONS: This study highlights that RRT acceptance rates are positively associated with social deprivation and the proportion of non-white people in a PCT/LHB, but regional variations in RRT acceptance rates still persist despite taking these into account. Further study is required to understand the extent to which these differences reflect variation in underlying need or provision of care.

Ethnicity, socioeconomic status, and attainment of clinical practice guideline standards in dialysis patients in the United kingdom.

BACKGROUND AND OBJECTIVES: The role of socioeconomic status (SES) and its contribution to ethnic differences in standards attainment among dialysis patients is not known. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We examined associations between area- level SES (Townsend index) and ethnicity (white, black, South Asian) and standards attainment in 14,117 incident dialysis patients (1997-2004) in the UK. RESULTS: Deprived patients were less likely to achieve hemoglobin (Hb) > or = 10 g/dl (trend P < 0.001) but not after controlling for patient and center characteristics (trend P = 0.1). There was no association with hemodialysis dose and parathyroid hormone (PTH) standard but deprived patients had better attainment of phosphate (PO4) <5.6 mg/dl, calcium (Ca) and Calcium-phosphate (CaPO4) standard (e.g., most deprived versus least deprived adjusted odds ratio [OR] 1.25, 95% confidence intervals [CI] 1.12, 1.38). There was no association with SES using a lower limit for PO4 (3.5 - 5.5 mg/dl). Compared with Whites, Blacks had lower attainment of Hb (adjusted OR 0.57, 95% CI 0.45, 0.71) and PTH standards (adjusted OR 0.27, 95% CI 0.22, 0.33) but better attainment of PO4 and CaPO4, while South Asians experienced better or comparable outcomes for most standards except Ca and PTH. CONCLUSIONS: There was no evidence of socioeconomic inequity in standards attainment or a consistent pattern of inequity by ethnic group. The lower attainment of some standards in ethnic minorities may reflect biologic differences rather than ethnicity-related inequity of care.