Glomerular disease patients have higher odds not to reach quality targets in chronic dialysis compared with CAKUT patients: analyses from a nationwide German paediatric dialysis registry.

BACKGROUND: Paediatric dialysis patients still suffer from high morbidity rates. To improve this, quality assurance programs like the German QiNKid (Quality in Nephrology for Children)-Registry have been developed. In our study, the significance of underlying renal disease on a range of clinical and laboratory parameters impacting morbidity and mortality was analysed. Our aim was to evaluate whether or not disease-specific dialysis strategies should be considered in planning dialysis for a patient. METHODS: Inclusion criteria were defined as follows: (1) CAKUT (congenital anomalies of the kidney and urinary tract) or glomerular disease patient, (2) < 18 years of age, (3) haemodialysis or peritoneal dialysis patient. Only measurements obtained from day 90 to 365 after the date of the first dialysis in the registry were analysed. Laboratory (serum albumin, haemoglobin, ferritin, calcium, phosphate, parathyroid hormone) and clinical parameters (height, blood pressure) were analysed using mixed effects models accounting for the correlation of repeated measures in individual patients. RESULTS: The study cohort comprised n = 167 CAKUT and n = 55 glomerular disease patients. Glomerular disease patients had significantly higher odds of hypoalbuminemia (OR 13.90, 95% CI 1.35-159.99; p = 0.0274), anaemia (OR 3.31, 95% CI 1.22-9.13; p = 0.0197), hyperphosphatemia (OR 9.69, 95% CI 2.65-37.26; p = 0.0006) and diastolic hypertension (OR 3.38, 95% CI 1.20-9.79; p = 0.0212). CONCLUSIONS: Glomerular disease patients might require more intensive dialysis regimens. The evaluation of hydration status should be given more attention, since conditions differing between the cohorts can be linked to overhydration. The QiNKid-Registry allows monitoring of the quality of paediatric dialysis in a nationwide cohort.

[Home hemodialysis]. / Heimhämodialyse: Aktuelle Aspekte und Wandel in der Nierenersatztherapie.

Home hemodialysis (HHD) is the cornerstone of renal replacement therapy in Germany. From 1969, it enabled survival with a diagnosis that up to then had been fatal; however, with the development of a good network of dialysis centers, the knowledge and experience of HHD was increasingly lost. Today, HHD is practically no longer included in the education. Insufficient information and a lack of HHD services are the result. Currently, less than 0.8% of patients in Germany are treated with HHD. In the development of dialysis machines, the industry focused on stand-alone machines for the centers. This form of treatment hinders mobility and limits the activities of patients with renal insufficiency requiring dialysis. Starting with the Advancing American Kidney Health Initiative there has been a welcome momentum in the development of innovative, wearable and implantable artificial kidneys. This can improve the quality of life and reduce the mortality rate. The first initiatives have also emerged in Germany and Europe. These innovative devices and the associated transition in renal replacement therapy will solve many problems of the nephrology community, such as personnel shortages or the lack of donor organs and death on the waiting list and give patients independence and mobility. The cost burden on healthcare systems can be reduced. In addition, the immense water and electricity consumption will be dramatically reduced by the regenerative techniques of the new machines.

[Home hemodialysis]. / Heimhämodialyse: Aktuelle Aspekte und Wandel in der Nierenersatztherapie.

Home hemodialysis (HHD) is the cornerstone of renal replacement therapy in Germany. From 1969, it enabled survival with a diagnosis that up to then had been fatal; however, with the development of a good network of dialysis centers, the knowledge and experience of HHD was increasingly lost. Today, HHD is practically no longer included in the education. Insufficient information and a lack of HHD services are the result. Currently, less than 0.8% of patients in Germany are treated with HHD. In the development of dialysis machines, the industry focused on stand-alone machines for the centers. This form of treatment hinders mobility and limits the activities of patients with renal insufficiency requiring dialysis. Starting with the Advancing American Kidney Health Initiative there has been a welcome momentum in the development of innovative, wearable and implantable artificial kidneys. This can improve the quality of life and reduce the mortality rate. The first initiatives have also emerged in Germany and Europe. These innovative devices and the associated transition in renal replacement therapy will solve many problems of the nephrology community, such as personnel shortages or the lack of donor organs and death on the waiting list and give patients independence and mobility. The cost burden on healthcare systems can be reduced. In addition, the immense water and electricity consumption will be dramatically reduced by the regenerative techniques of the new machines.

Vitamin D status and cancer prevalence of hemodialysis patients in Germany.

AIM: To describe Vitamin D (VitD) status and prevalence of cancer in a large cohort of ambulatory hemodialysis patients in Germany. PATIENTS AND METHODS: In a registry study adult patients starting dialysis between 2006 and 2012 were analyzed for VitD blood levels and International classification of diseases (ICD)-10 cancer diagnoses. RESULTS: Almost one third (32.7%) of patients initiating dialysis, had VitD levels<12.5 ng/ml and 79.7% had levels<30 ng/ml (n=8,377). Average VitD at dialysis initiation increased from 18.0 to 23.2 ng/ml between 2006 and 2012. Prevalence of cancer in this cohort was 22.1% with genital, renal and gastro-intestinal cancers being most common. Cancer frequencies were similar in patients with high and low vitamin D levels. CONCLUSION: Most chronic hemodialysis patients were vitamin D-deficient in spite of concurrent vitamin D supplementation. The burden of cancer was high in these patients. Future studies should address the role of vitamin D treatment on the course and progression of cancer in chronic kidney disease (CKD) patients.

[Participation of hospital nephrology departments in outpatient dialysis care. Joint Statement of the ¼Deutsche Gesellschaft für Nephrologie (DGfN)«, ¼Verband leitender Klinikärzte in der Nephrologie (VLKN)«, ¼Verband Deutsche Nierenzentren (DN) e.†V.« , ¼KfH Kuratorium für Dialyse und Nierentransplantation e.†V.« and ¼PHV - Der Dialysepartner Patienten-Heimversorgung«]. / Ambulante Dialyse an nephrologischen Krankenhausabteilungen. Gemeinsame Stellungnahme der Deutschen Gesellschaft für Nephrologie, des Verbandes leitender Klinikärzte in der Nephrologie, des Verbandes Deutsche Nierenzentren e.†V., des KfH Kuratorium für Dialyse und Nierentransplantation e.†V. und der PHV ­ Der Dialysepartner Patienten-Heimversorgung.

The proposals by health care providers to impose drastic limits on chronic dialysis in hospitals to the extent that it can only be provided on loss-making terms, will jeopardize the cost efficiency of nephrological departments in hospitals and hence their continued existence. Such departments play a key role within the discipline, however, as the training of nephrologists is tied to them by further training regulations. The authors take the view that the proposals by health care providers are short-sighted with regard to the quality of care and the safeguarding of care in the future, and that they counteract the goals of quality assurance currently dominating the health policy agenda.

Predictive value of initial histology and effect of plasmapheresis on long-term prognosis of rapidly progressive glomerulonephritis.

Intensive immunosuppressive therapy has improved the outcome of patients with rapidly progressive glomerulonephritis (RPGN), which progresses to end-stage renal failure in 90% of patients without intervention. However, it remains unclear which patients benefit most from immunosuppressive therapy and whether plasmapheresis improves long-term outcome. This prospective multicenter study randomized 39 patients with biopsy-proven RPGN (Couser type II, n = 6; pauci-immune type III, n = 33) to undergo either immunosuppressive therapy with prednisone and cyclophosphamide (n = 18) or plasmapheresis in addition to immunosuppression (n = 21). Patients were observed for a mean of 127 months or until reaching the end points of hemodialysis or death. Six of 11 patients who were initially dialysis dependent recovered renal function; however, 2 of those patients required dialysis therapy again after 10 and 105 months. Overall, 15 of 39 patients reached end-stage renal failure after a mean of 25 months, and 4 patients died before requiring hemodialysis therapy. Plasmapheresis had no significant effect on renal or patient survival in type II or pauci-immune (type III) RPGN, independently of age, sex, or serum creatinine level at the time of diagnosis. Overall, probabilities of dialysis-free survival were 0.80, 0.67, 0.55, and 0.48 after 12, 24, 60, and 120 months, respectively. Histological characteristics at the time of diagnosis predicted the effect of immunosuppression on renal outcome. All patients were dialysis dependent within 24 months if more than one third of glomeruli were totally sclerosed on the initial histological examination. Interstitial fibrosis also correlated significantly with the risk for progression to renal failure. Conversely, long-term dialysis-free survival was significantly more likely in patients with a greater number of crescents than in those with a low number of crescents. In conclusion, plasmapheresis does not add to the improvement in outcome reached by immunosuppression alone. Crescents on initial histological examination correlate with a favorable outcome. However, 90% of patients who initially have glomerular sclerosis present become dialysis dependent. Overall, approximately 50% of patients are alive and off dialysis therapy 10 years after the diagnosis of type II or type III RPGN using immunosuppression with cyclophosphamide and prednisone.