Temporal trends in prevalence and disability of chronic kidney disease caused by specific etiologies: an analysis of the Global Burden of Disease Study 2019.

BACKGROUND: The prevalence of disability in CKD is high. In this context the aim of the present study was to assess the  temporal trends of prevalence and disability progression for chronic kidney disease (CKD) caused by specific etiologies. METHODS: Using data from the Global Burden of Diseases Study (GBD) 2019, we examined the age-standardized rates of CKD prevalence and disability-adjusted life-years for different etiologies, including Type 1/2 diabetes mellitus (T1DM/T2DM), glomerulonephritis, and hypertension. We also calculated the average annual percentage changes to assess trends. Additionally, we utilized the joinpoint regression model to identify significant shifts over time. RESULTS: From 1990 to 2019, the global prevalence of CKD due to various etiologies exhibited an overall increasing trend, albeit with fluctuations. Notably, CKD due to T1DM, glomerulonephritis, and hypertension consistently demonstrated a significant upward trend across all continents, while the prevalence of CKD due to T2DM varied across continents. In terms of disability-adjusted life-years, CKD due to T2DM and hypertension exhibited a significant rising trend over the past 30 years. However, changes in age standardized disability-adjusted life-years for CKD due to different etiologies were not consistent across continents, with an upward trend observed in The Americas and a contrasting trend in Asia. Furthermore, both age-standardized prevalence rate and age standardized disability-adjusted life-year trends for CKD varied significantly across 204 countries and territories. Additionally, a negative association was observed between the Socio-demographic Index and the disability progression of CKD. CONCLUSION: The prevalence and disability burden of CKD caused by specific etiologies show substantial heterogeneity worldwide, highlighting significant disparities in the distribution of CKD. It is crucial to implement geographic and personalized strategies in different regions to alleviate the burden of CKD effectively.

Clinical characteristics of hospitalised children with acute post-streptococcal glomerulonephritis in the Top End of Australia.

AIMS: Despite the declining incidence of acute post-streptococcal glomerulonephritis (APSGN) in Australia, there is still a significant burden of disease amongst Aboriginal and Torres Strait Islander people in the Northern Territory. Childhood APSGN has been highlighted as a predictor of chronic kidney disease in this population. We aimed to describe clinical characteristics and outcomes of hospitalised children with APSGN in the Northern Territory. METHODS: Single-centre, retrospective cohort study of children (<18 years) with APSGN admitted to a tertiary hospital in the Top End of the Northern Territory between January 2012 and December 2017. Cases were confirmed using the Centre for Disease Control case definition guidelines. Data were extracted from the case notes and electronic medical records. RESULTS: There were 96 cases of APSGN with median age of 7.1 years (interquartile range (IQR) 6.7-11.4). Majority were Aboriginal and Torres Strait Islander (90.6%) and from rural and remote areas (82.3%). Preceding skin infections were identified in 65.5% and sore throat in 27.1%. Severe complications included hypertensive emergencies (37.4%), acute kidney injury (43.8%) and nephrotic-range proteinuria (57.7%). All children improved from their acute illness with supportive medical therapy; however, only 55 out of 96 (57.3%) children were followed up within 12 months of their acute illness. CONCLUSIONS: APSGN disproportionately affects Aboriginal and Torres Strait Islander children and highlights the need for continued and improved public health response. There is room for significant improvement in the medium- and long-term follow-up of affected children.

Socioeconomic Position and Incidence of Glomerular Diseases.

BACKGROUND AND OBJECTIVES: Social deprivation is a recognized risk factor for undifferentiated CKD; however, its association with glomerular disease is less well understood. We sought to investigate the relationship between socioeconomic position and the population-level incidence of biopsy-proven glomerular diseases. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In this retrospective cohort study, a provincial kidney pathology database (2000-2012) was used to capture all incident cases of membranous nephropathy (n=392), IgA nephropathy (n=818), FSGS (n=375), ANCA-related GN (ANCA-GN, n=387), and lupus nephritis (n=389) in British Columbia, Canada. Quintiles of area-level household income were used as a proxy for socioeconomic position, accounting for regional differences in living costs. Incidence rates were direct standardized to the provincial population using census data for age and sex and were used to generate standardized rate ratios. For lupus nephritis, age standardization was performed separately in men and women. RESULTS: A graded increase in standardized incidence with lower income was observed for lupus nephritis (P<0.001 for trend in both sexes) and ANCA-GN (P=0.04 for trend). For example, compared with the highest quintile, the lowest income quintile had a standardized rate ratio of 1.7 (95% confidence interval, 1.19 to 2.42) in women with lupus nephritis and a standardized rate ratio of 1.5 (95% confidence interval, 1.09 to 2.06) in ANCA-GN. The association between income and FSGS was less consistent, in that only the lowest income quintile was associated with a higher incidence of disease (standardized rate ratio, 1.55; 95% confidence interval, 1.13 to 2.13). No significant associations were demonstrated for IgA nephropathy or membranous nephropathy. CONCLUSIONS: Using population-level data and a centralized pathology database, we observed an inverse association between socioeconomic position and the standardized incidence of lupus nephritis and ANCA-GN.

Disease-specific incident glomerulonephritis displays geographic clustering in under-serviced rural areas of British Columbia, Canada.

There is little known about geographic variability in the incidence of glomerular disease and its potential implications for care delivery. To evaluate this, we performed a population-level cohort study using a provincial renal pathology database (2000-2012) to capture all incident cases of glomerulonephritis in British Columbia, Canada. This included 401 patients with membranous nephropathy (MN), 824 patients with IgA nephropathy (IgAN), 385 patients with focal segmental glomerulosclerosis (FSGS), 397 patients with lupus nephritis (LN) and 399 patients with ANCA-related glomerulonephritis (ANCA-GN). Geographic clusters were identified using Bayesian spatial models to estimate the incidence of each disease in 74 regions compared to the mean incidence in the entire province (incidence rate ratio, [IRR]), adjusted for region-level age, sex and race. The proportion of overall variability in incidence attributed to inter-regional differences varied by disease: 18% in MN, 81% in IgAN, 18% in FSGS, 59% in ANCA-GN, and 89% in LN. Except for LN, clustering was not explained by demographics. All IgAN and LN clusters were in urban regions close to nephrology centers, whereas ANCA-GN, MN and FSGS clustered mainly in rural regions. All ANCA-GN clusters were rural with median population density 1.2 persons/km2 and driving distances of 10-676 km to the nearest nephrology center. Thus, we found significant geographic clustering in the incidence of different glomerular diseases. MN, FSGS and ANCA-GN clustered in sparsely populated regions with limited access to care, underscoring the importance of regional variability in glomerular diseases to inform health services delivery.

Incidence, management, and outcomes of autoimmune nephropathies following alemtuzumab treatment in patients with multiple sclerosis.

BACKGROUND: Autoimmune disorders including nephropathies have been reported more frequently in alemtuzumab-treated multiple sclerosis (MS) patients than in the general population. OBJECTIVE: Describe instances of autoimmune nephropathy in alemtuzumab-treated MS patients. METHODS: Cases were identified from safety monitoring within the alemtuzumab relapsing-remitting multiple sclerosis (RRMS) clinical development program (CDP) or post-marketing, or following off-label use. RESULTS: As of 16 June 2017, 16 autoimmune nephropathies have occurred following alemtuzumab treatment for MS. The incidence of autoimmune nephropathies was 0.34% within the CDP (5/1485 patients). The five CDP cases (one of anti-glomerular basement membrane (anti-GBM) disease, two of membranous glomerulonephropathy, and two of serum anti-GBM antibody without typical anti-GBM disease) were identified early, responded to conventional therapy (where needed), and had favorable outcomes. Three of 11 cases outside the CDP occurred following off-label alemtuzumab use prior to approval for RRMS and were all anti-GBM disease. Diagnosis was delayed in one of these three cases and another did not receive appropriate treatment; all three cases resulted in end-stage renal failure. All anti-GBM disease cases with documented urinalysis demonstrated prior microscopic hematuria. CONCLUSION: Close monitoring of alemtuzumab-treated MS patients facilitates diagnosis and treatment early in the nephropathy course when preservation of renal function is more likely.

Post-streptococcal glomerulonephritis: Some reduction in a disease of disparities.

AIM: A retrospective Auckland-wide (total population approximately 1.4 million) study of hospital admissions from 2007 to 2015 was conducted to assess trends in admissions for acute post-streptococcal glomerulonephritis (APSGN) in children aged 0-14 years. METHODS: International Statistical Classification of Diseases (ICD10) discharge codes were used to identify potential cases of APSGN, and electronic clinical records and laboratory data were compared with established case definitions for definite or probable APSGN. RESULTS: A total of 430 cases of APSGN were identified (definite n = 337, probable n = 93), with a mean annual incidence of 15.2/100 000 (95% confidence interval (CI) 14.9-15.6). Incidence (0-14 years) was 17 times higher in Pacific peoples (50.2/100 000, 95% CI 48.6-51.8) and almost 7 times higher in Maori (19.6/100 000, 95% CI 18.6-20.7) than European/other populations (2.9/100 000, 95% CI 2.7-3.1). Multivariate analysis found ethnicity, deprivation, male gender, age (peak 3-8 years) and season (summer/autumn) to be associated with admission risk. Admission rates showed a significant change of -9.0% (95% CI -10.4, 7.4%) per year, with 2011 being an exception. Low C3 complement, hypertension, elevated streptococcal titres, oedema and heavy proteinuria were present in 94, 65, 67, 52 and 49% of cases, respectively. Relying on ICD10 codes without further review of clinical notes would result in an overcount of cases by 25%. CONCLUSIONS: There is severe disparity in APSGN admission rates, with a disproportionate burden of disease for Pacific and Maori children and those living in deprived circumstances. Rates trended downward from 2007 to 2015.

The population-level costs of immunosuppression medications for the treatment of glomerulonephritis are increasing over time due to changing patterns of practice.

Background: Immunosuppression (IS) is the main treatment for most types of glomerulonephritis (GN). Quantifying the cost of IS is necessary to ensure equitable access to therapies and optimal health outcomes, but the real-world cost of IS treatment for GN is largely unknown. We examined temporal changes in the population-level IS medication costs for GN over a 14-year period in a large Canadian province. Methods: We linked a provincial pathology database (containing all GN cases from 2000 to 2012) with renal and medication administrative databases to capture clinical characteristics and IS medications, with follow-up until 2013. The primary outcome (mean IS medication cost per treated patient each year) was evaluated for trends over time. Results: The cohort included 2983 GN patients followed for a mean of 5.7 years. The yearly per-patient medication cost increased 6.8-fold from $205 to $1394 (P < 0.001), with significant increases of 3.5-11.7-fold in anti-neutrophil cytoplasmic antibody (ANCA) vasculitis, focal segmental glomerulosclerosis, lupus nephritis, minimal change disease and membranous nephropathy (P ≤ 0.004), but no change in immunoglobulin A (IgA) nephropathy. The cost of mycophenolate mofetil, calcineurin inhibitors and rituximab increased significantly (P < 0.001) such that in 2000 they accounted for 17.6% of medication costs and were used by 2.2% of patients, which increased to 94.5% and 44.6%, respectively, in 2013. The costs of azathioprine, cyclophosphamide and prednisone increased only slightly or decreased. Patterns of drug use and contribution to cost varied by type of GN. Conclusions: These are the first population-level estimates of the IS treatment costs for GN, and demonstrate a striking increase due to changing practice patterns from older, cheaper medications to newer, more expensive therapies. These results provide important information to guide future health policy strategies and cost-effectiveness research in glomerular diseases.

The incidence, prevalence, and outcomes of glomerulonephritis derived from a large retrospective analysis.

The incidence and period prevalence of glomerulonephritis (GN) with resultant rates of death and end-stage renal disease (ESRD) in the United States are unknown. Therefore, we assessed the presumptive burden of GN in a 20% Medicare sample, 5,442,495 individuals, and an Optum Clinformatics Employer Group Health Plan sample of 13,712,946 individuals. GN was established using International Classification of Diseases, Ninth Revision, Clinical Modification claims-based algorithms. Outcomes were all-cause mortality and ESRD rates. Cox proportional hazards modeling was used to determine factors associated with outcomes in incident patients. For secondary (systemic immunologic disease) and primary GN, respectively, incidence rates per 100,000 patient-years were 134 (95% CI: 132-136) and 57 (56-58) in the Medicare cohort, and 10 (9-10) and 20 (19-21) in the health plan cohort. Period prevalence per 100,000 individuals was 917 (909-952) and 306 (302-311) in Medicare and 52 (51-54) and 70 (68-71) in the health plan. Death rates in incident Medicare patients were 3.9-fold higher for secondary and 2.7-fold higher for primary GN compared with no GN. ESRD rates were typically 1 to 2 orders of magnitude higher compared with no GN. In the Medicare cohort, women with incident secondary GN were less likely than men to progress to ESRD (hazard ratio: 0.70; 95% CI: 0.62-0.80) and death (0.82; 0.79-0.86). Black patients were more likely than white patients to progress to ESRD (secondary GN, 1.56; 1.31-1.85; primary GN, 1.57; 1.35-1.83), but not to death. Thus, in the United States, GN based on health claims data is associated with increased likelihood of progression to ESRD and death.

The gap between estimated incidence of end-stage renal disease and use of therapy.

BACKGROUND: Relatively few data exist on the burden of end-stage renal disease (ESRD) and use of renal replacement therapy (RRT)-a life-saving therapy-in developing regions. No study has quantified the proportion of patients who develop ESRD but are unable to access RRT. METHODS: We performed a comprehensive literature search to estimate use and annual initiation of RRT worldwide, and present these estimates according to World Bank regions. We also present estimates of survival and of etiology of diseases in patients undergoing RRT. Using data on prevalence of diabetes and hypertension, we modeled the incidence of ESRD related to these risk factors in order to quantify the gap between ESRD and use of RRT in developing regions. RESULTS: We find that 1.9 million patients are undergoing RRT worldwide, with continued use and annual initiation at 316 and 73 per million population respectively. RRT use correlates directly (Pearson's r = 0.94) with regional income. Hemodialysis remains the dominant form of RRT but there is wide regional variation in its use. With the exception of the Latin American and Caribbean region, it appears that initiation of RRT in developing regions is restricted to fewer than a quarter of patients projected to develop ESRD. This results in at least 1.2 million premature deaths each year due to lack of access to RRT as a result of diabetes and elevated blood pressure and as many as 3.2 million premature deaths due to all causes of ESRD. CONCLUSION: Thus, the majority of patients projected to reach ESRD due to diabetes or hypertension in developing regions are unable to access RRT; this gap will increase with rising prevalence of these risk factors worldwide.

Prospective population-based study on the burden of disease from post-streptococcal glomerulonephritis of hospitalised children in New Zealand: epidemiology, clinical features and complications.

AIM: A nationwide 24-month study was conducted (2007-2009), via the New Zealand Paediatric Surveillance Unit to define epidemiology and clinical features of acute poststreptococcal glomerulonephritis (APSGN) in children hospitalised with the illness. METHODS: Paediatricians (n = 215) were requested to report new hospitalised cases fulfilling a case definition of definite (haematuria with low C3 and high streptococcal titres or biopsy proven APSGN) or probable (haematuria with low C3 or high streptococcal titres). RESULTS: A total of 176 cases were identified (definite: n = 138, probable: n = 38) with 63% residing in the Auckland metropolitan region. Sixty-seven percent were in the most deprived quintile. Annual incidence (0-14 years) was 9.7/100,000 (Pacific 45.5, Maori 15.7, European/other 2.6 and Asian 2.1/100,000). Annual incidence was highest in the South Auckland Metropolitan region (31/100,000), Central Auckland 14.9, West/North Auckland metropolitan region 5.9 and for the remainder of New Zealand 5.5/100,000. Age-specific incidence was highest in age 5-9 years (15.1/100,000). Reduced serum complement C3, gross haematuria, hypertension, impairment of renal function and heavy proteinuria were present in 93%, 87%, 72%, 67% and 44% of patients, respectively. Severe hypertension was closely associated with either symptoms of an acute encephalopathy or congestive heart failure. CONCLUSIONS: New Zealand children carry a significant disease burden of hospitalised APSGN with socio-economically deprived; Pacific and Maori children are being over-represented. Significant short-term complications were observed in hospitalised children with APSGN. Persistently very low rates in European/other suggest a preventable disease.

Changing spectrum of biopsy-proven primary glomerular diseases over the past 15 years: a single-center study in China.

The prevalence of chronic kidney disease (CKD) is reported to be 10.8-11.8% of the Chinese population. With economic development and longer life expectancy, the spectrum of CKD etiology has kept changing. Primary glomerular diseases (PGD) are still the most common renal diseases in China. To investigate the changing pattern of PGD in China, we retrospectively analyzed consecutive native renal biopsies performed in our hospital from 1997 to 2011. The patients were grouped according to a 3-year interval, 1997-1999 (period 1), 2000-2002 (period 2), 2003-2005 (period 3), 2006-2008 (period 4), 2009-2011 (period 5), and divided into three age groups (<20, 20-59, and ≥60 years old). 8,909 qualified cases were enrolled in this study. Among 8,909 specimens, 6,337 (71.13%) were diagnosed as PGD, while this prevalence decreased significantly from 77.61% in 1997-1999 to 66.73% in 2006-2008. IgA nephropathy (IgAN) was the most common PGD (36.66%), without any significant difference in the 5 periods (p = 0.185). IgAN was the most common PGD both in patients between the 20- to 59-year-old group (45.58%) and <20-year-old group (19.29%) as well. Membranous nephropathy (MN) was the most frequently found PGD in patients at age ≥60 years (39.64%). The frequency of MN was increased significantly from 6.48% in 1997-1999 to 22.79% in 2009-2011 (p < 0.001). The proportion of elderly patients increased significantly from 3.18% in 1997-1999 to 15.21% in 2009-2011 (p < 0.001). The prevalence of endocapillary proliferative glomerulonephritis (EnPGN) has decreased since 1997. PGD has remained the most common renal disease in China, although with a descending trend. The spectrum of PGD is different in different age groups. The frequency of EnPGN has decreased significantly, while that of MN has increased significantly.

Kidney diseases in Africa: aetiological considerations, peculiarities and burden.

AIM: To review available literature on the burden of kidney diseases in Africa from the perspective of acute kidney injury and chronic kidney disease. It also aims to provide information on the status of renal replacement therapy activities, and the emerging roles of the double burden of communicable and non communicable diseases interfacing with the kidney in a continent with distinct environmental, socio-cultural, infrastructural and economical peculiarities. METHODS: A literature search was conducted on the aetiopathogenesis, management options of peculiar diseases causing both acute kidney injury and chronic kidney diseases and renal replacement therapies in Africa. The literature review used the electronic database; Medline, Pubmed and theAfrican Journal on line (AJOL). Information related to the topic over a 30-year period (1979-2009) was retrieved and reviewed. Search terms used were; acute renal failure in Africa, acute kidney injury in Africa, chronic renal failure/chronic kidney disease in Africa, heamodialysis, peritoneal dialysis and transplantation in Africa. RESULT: Nephrotoxins and infections are prevalent causes of acute kidney injury (AKI) in the continent. Chronic glomerulonephritis, hypertension and lately diabetes mellitus are still major peculiar aetiological factors of chronic kidney disease (CKD). A variety of renal syndromes which can be acute or chronic is associated with the Human immunodiefficency virus infection and its magnitude and consequences portend a grim reality in a continent that is least prepared to respond appropriately. Renal replacement therapy therapy is limited to less than five percent of those that need it especially in the sub-Saharan Africa. CONCLUSION: There is a huge burden of AKI and CKD in Africa from the perspective of their peculiar aetiological considerations. The status of renal replacement therapy activities is poor except in North and South Africa. The major challenges of kidney diseases in Africa include the high prevalence, delayed presentation, cost of treatment, general lack of preventive measures, lack of epidemiological studies and general lack of functional renal registries. There is thus a need for a strong advocacy for support for renal care in Africa.

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

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

The pattern, clinical characteristics and outcome of ESRD in Ile-Ife, Nigeria: is there a change in trend?

BACKGROUND: The prevalence of chronic renal failure and End Stage Renal Disease (ESRD) has remained high worldwide and the epidemiology has changed significantly in the last decade in industrialised countries. While there have been significant improvements in these patient's outcomes in developed countries, their state and survival is still appalling in developing countries. OBJECTIVE: To determine the clinical pattern, presentation and management outcomes in our ESRD population over a 19-year period (1989-2007). METHODS: Seven hundred and sixty patients' records were reviewed. Data on major causes, clinical presentation, management and survival were retrieved and collated. Data was analysed using SPSS package version 16. RESULTS: Their ages ranged between 15-90 years (mean ± SD; 39.9±1.67years) with male preponderance (70.3%). Major presenting complaints were body swelling and uraemic symptoms in most studied patients. The predisposing conditions included chronic glomerulonephritis, hypertension, obstructive uropathy and diabetes mellitus. Renal replacement therapy offered included HD in 556(73.2%), Continous Ambulatory Peritoneal Dialysis (CAPD) in only 9(1.2%) patients and renal transplantation in only 7(0.9%). Only 38(6.8%) survived on HD for longer than three months while 7(77.8%) CAPD patients and all transplanted patients survived for between six months and four years (p<0.00001). Median duration of survival after diagnosis for all the patients was 2 weeks (range 0-50 months). CONCLUSION: End stage renal disease is still prevalent with chronic glomerulonephritis and hypertension being the common causes. Prognosis is still grave hence subsidized renal replacement therapy and preventive nephrology should be targeted in such underserved populations.

[Management of a patient in condition of preterminal chronic renal insufficiency as criterion for probability assessment of risk factors].

It was modified the instant method of Caplan-Meiyer (worked out for the characteristic of the patients revealing) for calculation of a new criterion--preservation of the patient in the condition pre terminal chronic renal insufficiency (CRI). It was determined 102,5; 112,5; 122,5; 132,5; 142,5; 152,5; 162,5; 172,5; 182,5; 192,5; 202,5; 212,5; 222,5; 232.5; 242,5-monthly preservation of the patient in the condition pre terminal CRI, which was formed: (98.0 +/- 1.1)%, (92.8 +/- 1.8)%, (85.6 +/- 2.1)%, (75.9 +/- 2.4)%, (62.8 +/- 2.7)%, (51.0 +/- 2.5)%, (39.9 +/- 2.4)%, (30.7 +/- 2.1)%, (22.9 +/- 1.9)%, (17.0 +/- 1.6)%, (11.8 +/- 1.5)%, (7.9 +/- 1.3)%, (4.6 +/- 1.1)%, (1.9 +/- 0.6)%. It was shown that size of this parameter changed considerably subject to the initial reason of CRI the patient sex, adequateness of the medical providing, from harmful habits (smoking) and the presence of accompanying pathologies (comorbidity coefficient).

Glomerulonephritis in disadvantaged populations.

Glomerulonephritis (GN) still enjoys a high rank as a cause of chronic kidney disease (CKD) worldwide. Its burden is particularly manifest in disadvantaged populations, with a proportional contribution up to 6-folds compared to that in the USA. There are several overlapping risk factors that render a particular population "disadvantaged" in this respect. It is envisaged that these may be categorized into a triad of genetic, climatic and socioeconomic factors. An attempt is made to dissect the impact of each of these factors, which combine in different proportions in different populations thereby explaining regional disparity in the epidemiology, clinical manifestations and outcomes of CKD. The genetic impact is manifest in racial variations in the incidence of GN as a whole, the predominance of FSGS mainly in blacks and IgA nephropathy in Asians, the increased susceptibility to SLE and decreased incidence of IgAN and vasculitis in blacks, with similar trends in other "subraces" as Indians, Afro-Caribbean's, Martinique and other indigenous populations. The climatic impact is mainly displayed in the tropics, where the "rich bioecological environment" increases the incidence of infection-associated GN, usually proliferative with a few exceptions. The socioeconomic impact, reflecting low national economy in the developing world, modifies the two other arms of the triad according to the level of primary care, efficiency of the referral system and adequate management of primary infections as well as associated glomerular injury.

The current state of poststreptococcal glomerulonephritis.

Poststreptococcal glomerulonephritis is one of the oldest recognized renal diseases. In the past three decades, significant changes have occurred in its epidemiology, in new insight gained in the nephritogenic characteristics of streptococcal antigens, and in the natural history of the disease. The disease is now rare in industrialized nations, but in the underprivileged world, the burden of poststreptococcal glomerulonephritis ranges between 9.5 and 28.5 new cases per 100,000 individuals per year. Prophylactic antibiotic treatment is advisable in epidemic conditions and to household contacts of index cases in communities where the prevalence of the disease is high. The long-term prognosis is variable; in general, prognosis is excellent in children but significantly worse when it occurs in elderly individuals and in populations that present other risk factors of chronic kidney disease. Contemporary large-scale research strategies such as genome-wide sequencing may uncover new information about pathogenic factors contributing to disease.

High-efficiency short daily haemodialysis--morbidity and mortality rate in a long-term study.

BACKGROUND: In conventional haemodialysis (CHD), the morbidity and mortality rate is unacceptably high; consequently, variations in the length and frequency of the haemodialysis sessions have been studied to reduce the complications of dialysis treatment. In this sense, high-efficiency short daily haemodialysis (SDHD) has been proposed as an alternative for patients on renal replacement therapy. In this study, we have related our experience with this dialysis modality. METHODS: Twenty-six patients (16 males, mean age 35.6 +/- 14.7 years) were treated by SDHD for 33.6 +/- 18.5 months (range 6-57 months). The mean time on CHD before the switch to SDHD was 25.5 +/- 31.9 months (range 1-159 months). In 23 (88.5%) patients, native arteriovenous fistulae were used for vascular access. SDHD was performed six times a week, 1.5-2 h per session, and high flux polysulfone dialysers (surface area: 1.8 m(2)) were employed. The blood flow and dialysate flow rate were 350 and 800 ml/min, respectively. RESULTS: In this trial, the patient survival was 100%. The vascular access survival after 12, 24, 36 and 48 months on SDHD was 100, 89, 89 and 80%, respectively. There were three failures of vascular access in 72.7 patient-years (0.04 failures/patient-year). In 15 patients on SDHD during 36 consecutive months, the vascular access survival after 12, 24, 36 and 48 months was 100, 93, 93 and 84%, respectively. Also, in this group of patients, there were 0.27 hospitalizations/patient-year and 1.24 days of hospitalizations/patient-year. CONCLUSIONS: We concluded that in a long-time study of patients on SDHD the morbidity and mortality rate is very low. Furthermore, we observed that failures of vascular access are not a significant problem. Consequently, we believe that SDHD is a powerful renal replacement therapy for treatment of patients on maintenance haemodialysis.