Trends in the incidence and prevalence of end-stage renal disease with hemodialysis in entire Korean population: A nationwide population-based study.

ABSTRACT: Data on the overall epidemiology and temporal trends of end-stage renal disease (ESRD) requiring hemodialysis in Korea are scarce. We aimed to estimate the prevalence and incidence of ESRD requiring hemodialysis in Korea between 2002 and 2017.Using the National Health Insurance Service database, we analyzed data from the entire Korean population between 2002 and 2017. Hemodialysis patients were identified using rare incurable disease codes (V001) or prescription of medical fee codes of hemodialysis (O7020 and O7021). We only included patients who had been maintained on hemodialysis for more than 90 days from the date of dialysis initiation, to exclude patients who required short-term dialysis for acute kidney injury, conversion to peritoneal dialysis, or kidney transplantation.During the 16-year follow-up, the number of hemodialysis patients in Korea has steadily increased from 11,215 in 2002 to 67,486 in 2017. The mean age of these patients has gradually increased from 55.57 ±â€Š13.31 years in 2002 to 62.13 ±â€Š13.23 years in 2017. In 2017, the crude prevalence rate of hemodialysis was 1303.4 per million population. Overall, the number of men tended to be somewhat higher than that of women, and the proportion of men increased slightly from 55.56% in 2002 to 58.45% in 2017. The proportion of diabetic patients increased rapidly from 23.84% to 47.84%, and the percentage of dyslipidemic patients rose from 18.9% to 86.7%. The number of incident hemodialysis patients increased significantly from 4406 in 2003 to 12,134 in 2014, and then decreased to 8090 in 2017. In the incident cases of hemodialysis, the observed increase in the proportion of male patients and in diabetes and dyslipidemia were similar to that of prevalent patients. The more recent era of hemodialysis initiation, the better 5-year survival rates were observed.The prevalence and incidence of hemodialysis in Korea gradually increased between 2002 and 2017. The proportion of men, and patients with diabetes and dyslipidemia requiring hemodialysis also increased continuously. The survival rate of hemodialysis patients was gradually improving. These findings may serve as a reference for future epidemiological studies on hemodialysis in Korea.

Caring for Migrants and Refugees With End-Stage Kidney Disease in Europe.

With the number of migrants and refugees increasing globally, the nephrology community is increasingly confronted with issues relating to the management of end-stage kidney disease in this population, including medical, logistical, financial, and moral-ethical questions. Beginning with data for the state of affairs regarding refugees in Europe and grounded in moral reasoning theory, this Policy Forum Perspective contends that to improve care for this specific population, there is a need for: (1) clear demarcations of responsibilities across the societal (macro), local (meso), and individual (micro) levels, such that individual providers are aware of available resources and able to provide essential medical care while societies and local communities determine the general approach to dialysis care for refugees; (2) additional data and evidence to facilitate decision making based on facts rather than emotions; and (3) better information and education in a broad sense (cultural sensitivity, legal rights and obligations, and medical knowledge) to address specific needs in this population. Although the nephrology community cannot leverage a change in the geopolitical framework, we are in a position to generate accurate data describing the dimensions of care of refugee or migrant patients with end-stage kidney disease to advocate for a holistic approach to treatment for this unique patient population.

A propensity-matched comparison of hard outcomes in children on chronic dialysis.

Data concerning outcomes of children on hemodialysis (HD) and peritoneal dialysis (PD) are scarce and frequently derived from single-center experiences. We sought to compare survival and transplantation rates in a large cohort of PD and HD patients. We extracted all patients initiating dialysis under 16 years of age between 2004 and 2013 from the Italian Registry of Pediatric Chronic Dialysis. Patients on PD were propensity-matched to those on HD based on gender, age, primary cause of ESRD, and the number of co-morbidities. Stratified Cox proportional hazard models were used to compare outcomes by dialysis modality. Three hundred ten patients were matched from 452 incident patients. In the unmatched cohort, PD patients were younger, more likely to be diagnosed with CAKUT, and had a higher urine output than HD patients. In the propensity-matched cohort, covariates were balanced between the two groups. At 2 years, the cumulative hazard ratio for death was similar (CHR 0.95, 95% CI 0.17-5.20) for HD relative to PD patients; and at 5 years, the CHR was lower for HD patients (0.22 95% CI 0.16-0.29). The cumulative incidence of transplantation at 3 years after dialysis initiation was 60.9% in HD patients and 59.7% in PD patients, with a CHR of 1.03 (95% CI 0.73-1.45). CONCLUSIONS: Pediatric PD and HD patients have distinct characteristics. After controlling for treatment-selection biases, children selected to start on PD or HD exhibit a similar mortality risk during the first 2 years on treatment, after which this risk increases in PD children. What is Known: • Few studies have compared hard outcomes in children on maintenance dialysis. • Children started on different dialysis modalities have distinct characteristics that impact on survival. What is New: • After controlling for treatment-selection biases, children selected to start dialysis on PD or HD exhibit a similar mortality risk during the first 2 years on treatment, after which this risk appears to be increased in PD children. • An "integrative care" approach should be used in children on PD, switching them to HD when PD-related morbidity tends to increase.

Outcomes of renal replacement therapy in boys with prune belly syndrome: findings from the ESPN/ERA-EDTA Registry.

BACKGROUND: As outcome data for prune belly syndrome (PBS) complicated by end-stage renal disease are scarce, we analyzed characteristics and outcomes of children with PBS using the European Society for Pediatric Nephrology/European Renal Association-European Dialysis and Transplant Association (ESPN/ERA-EDTA) Registry data. METHODS: Data were available for 88 male PBS patients aged <20 years who started renal replacement therapy (RRT) between 1990 and 2013 in 35 European countries. Patient characteristics, survival, and transplantation outcomes were compared with those of male patients requiring RRT due to congenital obstructive uropathy (COU) and renal hypoplasia or dysplasia (RHD). RESULTS: Median age at onset of RRT in PBS was lower [7.0; interquartile range (IQR) 0.9-12.2 years] than in COU (9.6; IQR: 3.0-14.1 years) and RHD (9.4; IQR: 2.7-14.2 years). Unadjusted 10-year patient survival was 85% for PBS, 94% for COU, and 91% for RHD. After adjustment for country, period, and age, PBS mortality was similar to that of RHD but higher compared with COU [hazard ratio (HR) 1.96, 95% confidence interval (CI) 1.03-3.74]. Seventy-four PBS patients (84%) received a first kidney transplant after a median time on dialysis of 8.4 (IQR 0.0-21.1) months. Outcomes with respect to time on dialysis before transplantation, chance of receiving a first transplant within 2 years after commencing RRT, and death-censored, adjusted risk of graft loss were similar for all groups. CONCLUSIONS: This study in the largest cohort of male patients with PBS receiving RRT to date demonstrates that outcomes are comparable with other congenital anomalies of the kidney and urinary tract, except for a slightly higher mortality risk compared with patients with COU.

Acute hypocalcemia following kidney transplantation may depend on the type of remote parathyroidectomy: a retrospective cohort study
.

BACKGROUND: Secondary hyperparathyroidism is a common complication of chronic kidney disease. When medical management fails, parathyroidectomy (PTX) is a treatment option. The two most common types are subtotal PTX and total PTX with autotransplantation (AT). To date, there is no consensus as to which procedure is preferable, especially in patients who are candidates for future kidney transplantation. The aim of this study was to identify if the type of PTX is a risk factor for acute postrenal transplant (postRTX) hypocalcemia and a concern for problems with long-term calcium homeostasis. METHODS: Renal transplant recipients at Rhode Island Hospital from 2005 to 2014 were screened for prior PTX. Out of 297 participants, 11 patients met the criteria. They were further divided into subtotal PTX (n = 5) vs. total PTX+AT (n = 6). Immediate postoperative (14 days) and long-term (1 year) calcium levels were followed and analyzed. Linear growth models were used to determine the effects of type of parathyroidectomy (subtotal PTX, total PTX+AT) alone on hypocalcemia over time. In these models, pretransplant levels of calcium and PTH were included as covariates. RESULTS: Baseline characteristics showed that prerenal transplant (preRTX) parathyroid hormone (PTH) levels were lower in total PTX+AT vs. subtotal PTX (3.5 vs. 247.2 mg/dL, p < 0.005). PreRTX calcium levels were slightly lower in subtotal PTX (9.5 vs. 8.25 mg/dL, p < 0.01), but were within normal limits for both groups. No significant differences were noted between total vitamin D levels and time between PTX and RTX. Within 14 days postRTX, the total PTX+AT group had lower average calcium levels (5.8 vs 8.8 mg/dL, p < 0.001); however, both groups had normal and stable calcium levels from 1 month to 1 year after transplant. This was further supported after adjusting for preRTX levels of calcium and PTH, showing a significant interaction between treatment and time such that patients had lower calcium levels if they underwent total PTX+AT vs. subtotal PTX within 14 days postRTX (ß = -0.204, SE = 0.039, p < 0.001) (Figure 1) but not at 1 year postRTX (ß = 0.035, SE = 0.075, p = 0.640). CONCLUSION: This study suggests that total PTX+AT increases the risk for acute postRTX hypocalcemia but has no effect on long-term calcium homeostasis. We speculate that the acuity of the hypocalcemia may be compounded by high-dose glucocorticoids required for induction, in addition to the preoperative undetectable PTH. Thus, prior to RTX, physicians should take into account the type of remote PTX. If a patient had a total PTX+AT, then postRTX hypocalcemia is likely to occur.
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Comparación entre los niveles de carnitina libre y el estado nutricional en pacientes con cistinosis nefropática infantil / Comparison of free carnitine levels with nutritional status in infantile nephropathyc cistinosis patients

Introducción: la cistinosis nefropática infantil (CNI) es una enfermedad genética debida a un defecto del transporte de la cistina, con la subsecuente acumulación de este aminoácido predominantemente en el riñón. Existen pocos estudios sobre la evaluación del estado nutricional en pacientes con esta patología, pero se sabe que tienen una excreción de carnitina urinaria aumentada, lo que puede dar como resultado una deficiencia plasmática y muscular de este compuesto; sin embargo, la suplementación de carnitina en CNI es controversial. Objetivo: comparar la concentración sanguínea de carnitina libre (C0) con el estado nutricional de una cohorte de pacientes con CNI. Material y métodos: evaluación antropométrica mediante la medición de peso, talla, perímetro braquial (PB) y pliegue cutáneo tricipital (PCT). La C0 se cuantificó mediante espectrometría de masas en tándem en muestras de sangre en ayuno. Resultados: se analizaron 10 pacientes con CNI, 5 con y 5 sin trasplante renal. De acuerdo con el IMC, 3/10 presentaron desnutrición. La reserva de masa magra se encontró baja en 8/10 pacientes (3 no trasplantados y todos los trasplantados). El PB mostró correlación con las concentraciones sanguíneas de C0 (r2=0,353); Los pacientes no trasplantados tuvieron niveles de C0 significativamente más bajos que los trasplantados (Chi2=0,0027). Conclusión: en esta población de pacientes con CNI se encontró un 70% de sujetos con C0 baja, que se correlaciona con la masa magra disminuida. Es recomendable hacer una evaluación nutricional de rutina que incluya los tres parámetros antropométricos como parte del seguimiento médico-nutricional integral de estos pacientes (AU)

Introduction: infantile nephropathic cystinosis (INC) is an autosomal recessive disorder that causes defects in cystine transport with subsequent accumulation in almost all body tissues, especially kidneys. There are few studies regarding the nutritional status assessment of patients with INC. It has been reported that patients with INC showed increased urinary losses of carnitine, resulting in plasma and muscle carnitine deficiency also increased metabolic requirements of carnitine in this patients have also been proposed, but to date carnitine supplementation is controversial. Objective: the aim of this study was to compare carnitine blood concentrations with nutritional status assessed by three anthropometric parameters: body mass index, mid-upper arm circumference and tricipital skin fold in patients with INC. Material and methods: anthropometric assessment of 10 patients with INC which included measurement of weight, height, mid-upper arm circumference and tricipital skin fold thickness. Free carnitine (C0) was measured by tandem mass spectrometry in fasting blood samples. Results: a total of 10 patients with INC were analyzed, 5 with and 5 without renal graft. According to the body mass index, 3/10 presented malnutrition. Muscular mass was found low in 8/10 patients (3 without renal graft and all the transplanted) the mid-upper arm circumference showed correlation with C0 blood concentrations (r2=0.353); non transplanted patients had C0 levels significantly lower than the transplanted ones (Chi2=0.0027). Conclusion: in this study we found that 70% of patients had low C0 blood levels that had a correlation with depleted lean body mass. It is recommendable to evaluate the nutritional status of these patients as part of their routine medical evaluation (AU)

Disparities in treatment rates of paediatric end-stage renal disease across Europe: insights from the ESPN/ERA-EDTA registry.

BACKGROUND: Considerable disparities exist in the provision of paediatric renal replacement therapy (RRT) across Europe. This study aims to determine whether these disparities arise from geographical differences in the occurrence of renal disease, or whether country-level access-to-care factors may be responsible. METHODS: Incidence was defined as the number of new patients aged 0-14 years starting RRT per year, between 2007 and 2011, per million children (pmc), and was extracted from the ESPN/ERA-EDTA registry database for 35 European countries. Country-level indicators on macroeconomics, perinatal care and physical access to treatment were collected through an online survey and from the World Bank database. The estimated effect is presented per 1SD increase for each indicator. RESULTS: The incidence of paediatric RRT in Europe was 5.4 cases pmc. Incidence decreased from Western to Eastern Europe (-1.91 pmc/1321 km, P < 0.0001), and increased from Southern to Northern Europe (0.93 pmc/838 km, P = 0.002). Regional differences in the occurrence of specific renal diseases were marginal. Higher RRT treatment rates were found in wealthier countries (2.47 pmc/€10 378 GDP per capita, P < 0.0001), among those that tend to spend more on healthcare (1.45 pmc/1.7% public health expenditure, P < 0.0001), and among countries where patients pay less out-of-pocket for healthcare (-1.29 pmc/11.7% out-of-pocket health expenditure, P < 0.0001). Country neonatal mortality was inversely related with incidence in the youngest patients (ages 0-4, -1.1 pmc/2.1 deaths per 1000 births, P = 0.10). Countries with a higher incidence had a lower average age at RRT start, which was fully explained by country GDP per capita. CONCLUSIONS: Inequalities exist in the provision of paediatric RRT throughout Europe, most of which are explained by differences in country macroeconomics, which limit the provision of treatment particularly in the youngest patients. This poses a challenge for healthcare policy makers in their aim to ensure universal and equal access to high-quality healthcare services across Europe.

Demographics of paediatric renal replacement therapy in Europe: a report of the ESPN/ERA-EDTA registry.

BACKGROUND: The ESPN/ERA-EDTA Registry collects data on European children with end-stage renal disease receiving renal replacement therapy (RRT) who are listed on national and regional renal registries in Europe. In this paper we report on the analysis of demographic data collected from 2009 to 2011. METHODS: Data on primary renal disease, incidence, prevalence, 4-year survival, transplantation rate and causes of death in paediatric patients receiving RRT were extracted from the ESPN/ERA-EDTA Registry for 37 European countries. RESULTS: The incidence of RRT in paediatric patients in Europe during the study period was 5.5 cases per million age-related population (pmarp) in patients aged 0-14 years and varied markedly between countries (interquartile range 3.4-7.0 years). The prevalence of RRT was 27.9 pmarp and increased with age, with 67 % of prevalent patients living with a functioning graft. The probability of receiving a transplant within 4 years was 76.9 % and was lowest in patients aged 0-4 years (68.9 %). Mortality in paediatric patients treated with RRT was 55-fold higher than that of the general EU paediatric population. Overall survival at 4 years was 93.7 %, with the poorest survival in patients aged 0-4 years and in patients starting on dialysis. Infections (19.9 %) were the primary cause of death in European paediatric RRT patients. CONCLUSION: Considerable variation exists in the current demographics of children treated with RRT across Europe.

Vitamin D and kidney transplant outcomes: a protocol for a systematic review and meta-analysis.

BACKGROUND: Patients with end-stage renal disease who receive kidney transplants have improved survival and quality of life compared to patients on dialysis. Unfortunately, transplant patients often have a low vitamin D concentration, which has well-known effects on calcium and bone metabolism. The effect of vitamin D on other indicators of transplant function, such as glomerular filtration rate and acute rejection, remains unknown. METHODS/DESIGN: We will conduct a systematic review of vitamin D status and outcomes after kidney transplantation. The primary objective is to assess the relationship between vitamin D and graft function using measured glomerular filtration rate (GFR) or estimated GFR from serum creatinine concentrations. Secondary outcomes will include acute rejection, chronic allograft nephropathy, proteinuria and graft loss. We will search MEDLINE, EMBASE, AMED and CINAHL for randomized and observational studies on adult renal transplant patients who received vitamin D supplementation or had serum vitamin D concentration measured. We will report study quality using the Cochrane Risk Assessment Tool for randomized controlled trials and the Newcastle-Ottawa Scale for observational studies. Quality across studies will be assessed using the GRADE approach. If pooling is deemed appropriate, we will perform meta-analyses using standard techniques for continuous and discrete variables, depending on the outcome. The results of this review may inform guideline development for vitamin D supplementation in renal transplant patients and highlight areas for further research. SYSTEMATIC REVIEW REGISTRATION PROSPERO: CRD42013006464.

UK Renal Registry 16th annual report: chapter 6 demographics and outcomes of patients from different ethnic groups on renal replacement therapy in the UK.

INTRODUCTION: This chapter describes the patient characteristics and outcomes for the three main ethnic groups (White, South Asian, Black) on renal replacement therapy (RRT) in the UK. METHODS: Data on patients (>18 years old) from all 71 UK adult renal centres starting RRT between 2003 and 2012 were considered. Scottish centres were excluded due to poor ethnicity data. RESULTS: The age-gender standardized incidence ratio of RRT was higher (2-3 times) in regions with a high ethnic minority population compared to those with a low ethnic minority population. South Asian and Black patients were significantly younger than Whites; had more diabetes causing established renal failure and lived in more deprived areas. The proportion of patients with at least one comorbidity was greater amongst White patients compared to South Asian and Black patients. The proportion of patients starting PD and having preemptive transplantation was lower amongst both ethnic minorities. The attainment of various laboratory standards was comparable or better for the ethnic minorities compared to White patients except for calcium standard attainment (for South Asians) and haemodialysis dose attainment (for Black patients). Compared to White patients, both ethnic minorities had similar rates of listing for deceased donor kidney transplantation but had lower rates of transplantation once wait-listed, and lower rates of living kidney donor transplantation. One and five year kidney allograft adjusted survival was poorer for Black patients but similar for South Asians compared to White patients. Black and South Asian patients had a better adjusted survival on dialysis compared to White patients. CONCLUSIONS: The persistent high incidence of RRT, the better survival on dialysis and the poor access to kidney transplantation for South Asian and Black patients and early allograft loss for Black patients will impose a disproportionate demand on dialysis provision in those areas with a high ethnic minority population.

Donor phosphorus levels and recipient outcomes in living-donor kidney transplantation.

BACKGROUND AND OBJECTIVES: In living-donor kidney transplantation, various donor factors, including gender, age, and baseline kidney function, predict allograft function and recipient outcomes after transplantation. Because higher phosphorus is predictive of vascular injury in healthy adults, the effect of donor phosphorus levels on recipient renal function after transplantation was investigated. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: Phosphorus levels in 241 living donors were analyzed from a 7-year period, and recipient renal function and acute rejection at 1 year posttransplantation were examined controlling for other influencing factors, including multiple donor variables, HLA matching, and acute rejection. RESULTS: Female and African-American donors had significantly higher phosphorus levels predonation. By multivariable analysis, higher donor phosphorus correlated with higher recipient serum creatinine (slope=0.087, 95% confidence interval [CI]: 0.004 to 0.169, P=0.041) and lower recipient estimated GFR (slope=-4.321, 95% CI: -8.165 to -0.476, P=0.028) at 12 months. Higher donor phosphorus also displayed an independent correlation with biopsy-proven acute rejection and delayed or slow graft function after transplantation. CONCLUSIONS: In a cohort of living kidney donors, higher donor phosphorus correlated with female gender and African-American ethnicity and was an independent risk factor for early allograft dysfunction after living-donor kidney transplantation.

Resource settings have a major influence on the outcome of maintenance hemodialysis patients in South India.

Chronic kidney disease is reaching epidemic proportions and the number of patients on renal replacement therapy (RRT) is increasing worldwide and also in developing countries. To meet the challenge of providing RRT, a few charity organizations provide hemodialysis units for underprivileged patients, as the private hospitals are unaffordable for the majority. There is a paucity of information on the outcome of dialysis in these patients. Here, we describe the outcome of hemodialysis patients comparing the middle- and upper-class income group with the lower class income group. A retrospective analysis was carried out in 558 CKD patients initiated on maintenance hemodialysis in two different dialysis facilities. Group A (n=247) included those who belonged to the lowermost socioeconomic status and were undergoing dialysis in two nonprofit, charity (TANKER)-run dialysis units, and Group B (n=311) was undergoing dialysis in a nonprofit hospital setting where no subsidy was given. Those patients of a low socioeconomic status, especially those who are diabetics, have a higher death rate (Group A-38.1%, Group B-4.2%) and loss to follow-up (Group A-25.9%, Group B-0.3%) compared with those who are in the middle- and high-income group. Higher EPO use and hence higher hemoglobin levels (Group A-6.4+/-1.2, Group B-8.9+/-1.5 P<0.001) were observed in those who were in the middle and the higher income group. Lower serum phosphorus level was observed in the low-socioeconomic group (Group A-4.7+/-1.5, Group B-5.5+/-1.9, P<0.001). Patients belonging to the middle and higher socioeconomic group undergo more transplantations compared with the lower socioeconomic group (Group A-2.4%, Group B-65.6%).

Social deprivation, ethnicity, and access to the deceased donor kidney transplant waiting list in England and Wales.

BACKGROUND: Socioeconomic and ethnic inequity in access to kidney transplant waiting list has been described in the United States but not examined in a universal healthcare system. METHODS: Eleven thousand two hundred ninety-nine patients aged 18 to 69 years starting renal replacement therapy (January 1, 1997 to December 31, 2004) in England and Wales were included. Multivariable Cox proportional hazards models were used to assess time to activation on the transplant waiting list for socially deprived patients among white patients. The effect of ethnic origin (South Asians and blacks compared with whites) was examined among all patients. RESULTS: Among white patients, in the fully adjusted model, the hazard ratio (HR) for the most deprived quintile was 0.60 (95% confidence interval [CI] 0.54-0.68, P trend <0.0001) compared with the least deprived. Deprivation effects were more pronounced among those 50 years and older (P value for interaction <0.0001). Non-whites had a lower risk of being waitlisted than whites (for blacks: HR 0.89, 95% CI 0.79-1.01; for South Asians: HR 0.91, 95% CI 0.83-0.99, P value for heterogeneity=0.03). These differences were attenuated in a fully adjusted model. However non-whites who were 50 years and older were more likely to be transplant waitlisted than whites (interaction P=0.002). CONCLUSIONS: Individuals living in socially deprived areas have reduced access to the transplant waiting list. Understanding the reasons for this apparent inequity is important if we wish to ensure equitable access to renal transplants. There were no major differences by ethnicity, and if anything, older white patients were less likely to be waitlisted.

More than 1,000 kidney transplants in a single year by the "Hospital do Rim" Group in Sao Paulo - Brazil.

We describe the organization of a high-volume Brazilian kidney transplant program that performed 7,833 transplants in 12 years fulfilling government expectations without compromising the care of the patients. The annual number of kidney transplants increased from 428 in 1999 to 1,048 in 2010. In our Organ Procurement Organization (6.1 million inhabitants) brain death notifications increased from 196 to 468 in 2010 and 35% became actual donors. There are 5,011 patients on the waiting list and recipient selection is based on HLA matching. A significant proportion of the recipients is of black ethnicity and had been for long time on dialysis. Over 700 first appointments for living donation are done every year. After the transplant, the majority of patients are followed locally (200-250 appointments per day). The transplant outcome among living-donor recipients is comparable to large registries but inferior outcome have been observed among recipients of deceased donor organs, though consistent improvement has been seen in more recent years. We also discuss issues related to local regulations and solutions to improve efficiency and outcomes.

End-stage renal disease in Indonesia: treatment development.

The number of cases of chronic kidney disease is growing rapidly, especially in the developing world. At a certain level of renal function, progression of chronic kidney disease to endstage renal disease (ESRD) is inevitable. ESRD has become a major health problem because it is a devastating medical condition, and the cost of treatment is a huge economic burden. This article presents data collected from 13 nephrology centers in response to specifically designed questionnaires. These centers were divided into 7 groups on the basis of geographic location. Previous data had given the impression that the incidence and prevalence of ESRD had increased, and the results of this study support these previous data. Since a national registry of ESRD has just been developed for Indonesia and we can present only limited data in this study, the numbers in this article underestimate the true incidence and prevalence rates. Although hemodialysis facilities have been developed rapidly, further development is still required. Continuous ambulatory peritoneal dialysis as an alternative renal replacement therapy (RRT) is only now being introduced. Kidney transplantation programs expand very slowly. RRT still imposes a high cost of treatment for ESRD; therefore, these treatments are unaffordable for most patients. Recently, government health insurance has covered financially strained families requiring RRT. Since the cost of RRT for ESRD has significantly increased over time, the management approach should be shifted from treatment to prevention.

Achieving chronic kidney disease treatment targets in renal transplant recipients: results from a cross-sectional study in Spain.

BACKGROUND: Kidney transplant recipients are considered to have chronic kidney disease (CKD) irrespective of glomerular filtration rate (GFR) or presence or absence of markers of kidney damage. The aim of this work was to investigate the prevalence of CKD-stages and whether the guidelines for general population (Kidney Disease Outcomes Quality Initiative) are routinely followed in kidney transplant in Spain. PATIENTS AND METHODS: Two thousand one hundred sixty renal transplant recipients followed up at the outpatient clinics in 4 University Hospitals were included. The estimated GFR (eGFR) was calculated according to the abbreviated modification of diet in renal disease equation, and the patients were classified following the Kidney Disease Outcomes Quality Initiative stages. RESULTS: Chronic kidney failure (eGFR <60 mL/min/1.73 m) was present in 1505 patients (69.7%), 54.4% were 3T-stage (eGFR 30-59); 13.0% were 4T-stage (eGFR 15-30), and 2.3% were 5T-stage. The prevalence of severe anemia increased from 4.1% in 1T-stage to 44% in 5T-stage (P=0.000) as did the percentage of patients on erythropoiesis-stimulating agents from 1.3% to 68% (P=0.000). The intact parathyroid hormone levels increased as graft function declined and 45% of 5T-stage patients had intact parathyroid hormone levels more than 300. Calcium and vitamin D supplements were administered to 50% and 40% of patients, respectively. Hypertension was quite common and increased with the progression of CKD. The mean total cholesterol was 192+/-39 mg/dL, and the levels did not increase with the decline in graft function. Approximately 60% had suboptimal cholesterol despite 50% being on statins treatment. CONCLUSIONS: CKD and their complications were prevalent in renal transplant recipients. The control of some of these complications is far below targets established for nontransplant CKD patients despite a progressive intensification of therapy as graft function declines.

Gift exchange and organ donation: donor and recipient experiences of live related kidney transplantation.

BACKGROUND: Live transplantation presents many stressors for donors and recipients, yet a holistic understanding of the process, from both perspectives, is limited. Gift exchange is a theory governed by the principles of giving, receiving and reciprocating and has many similarities with the process of organ transplantation. It may therefore provide a framework for understanding donor and recipient experiences of live kidney transplantation. However, the relevance of this theory to live kidney transplantation has not previously been properly explored. OBJECTIVES: To gain a theoretical understanding of the live transplantation experience from the perspectives of donors and recipients. DESIGN: A phenomenological, longitudinal study. PARTICIPANTS: All donors and their recipients undergoing live kidney transplantation in a regional renal transplant centre in South-West England (between July 2003 and February 2004) were invited to participate in this study. Of this cohort, 11 families (n=55%) volunteered to participate. METHODS: Data were collected through a series of 3 recorded, semi-structured interviews with donors and recipients. Interviews were conducted pre transplant and at 3 and 10 months post transplant. Data were analysed using a process of thematic content analysis. Findings were also considered within a theoretical framework of gift exchange. RESULTS: All donors initially made an instantaneous, voluntary decision to donate and found the decision relatively easy to make. In contrast, recipients found accepting the donors' offer arduous, because of concern for their wellbeing. They were only able to accept the transplant after discussing the matter with their donor and establishing that it was something that they wanted to do. Recipients' lives were transformed by a successful transplant and they were subsequently very grateful to the donors for donating. Donors derived immense personal satisfaction from this outcome and it helped to confirm to them that what they had done had been worthwhile. The transplant did not have a detrimental effect on donor-recipient relationships. CONCLUSIONS: The concept of gift exchange provides a logical explanation of donor and recipients experiences in this study, particularly in relation to factors that influence giving, receiving and reciprocating. This understanding should help health professionals assist donors, recipients and their families throughout this process.

Transitional cell carcinoma in renal transplant recipients: a single center experience.

OBJECTIVE: To present a single center experience in managing transitional cell carcinoma (TCC) in Chinese renal transplant (RTx) recipients. METHODS: In a cohort of 1429 patients who received RTx operation, 27 patients (six males and 21 females) were pathologically diagnosed with TCC in their native urologic system. The data were analyzed retrospectively. RESULTS: The incidence of TCC was 1.89% and accounted for 41.5% of the patients with post-transplant de novo malignancies among 1429 recipients. Among the 27 recipients with TCC, 77.8% were female, 59.3% had taken a Chinese herb that contains aristolochic acid for at least 2 months before RTx, 51.9% had painless gross hematuria, while 40.7% had microscopic hematuria and/or repeated urologic infection. Two patients were found to have asymptomatic hydronephrosis during a routine check-up. The patients with upper tract carcinoma underwent simultaneous bilateral nephroureterectomy or unilateral nephroureterectomy and bladder cuff resection. Transurethral resection of the bladder tumor was carried out in patients with concomitant or solitary superficial bladder lesions. Intravesical chemotherapy was started and immunosuppressants were adjusted in all patients immediately after the surgery. Tumor recurrence in the bladder was noted in five patients. In one patient, residual and/or recurrent carcinoma in the contralateral pelvis was detected. CONCLUSIONS: Transitional cell carcinoma is the predominant malignancy in Chinese RTx recipients. Female sex, the Chinese herb containing aristolochic acid and immunosuppression are markedly associated with the development of TCC. Risk-adapted screening, strict follow up, standard surgical intervention and dose reduction of immunosuppressants are very important for early diagnosis and treatment of TCC.

Fish oil treatment for kidney transplant recipients: a meta-analysis of randomized controlled trials.

BACKGROUND: Calcineurin inhibitors have adverse effects that contribute to nephrotoxicity and cardiovascular risk profile, and these may be reduced by administration of fish oil. The aim of this review was to assess the benefits and harms of fish oil supplementation in kidney transplant recipients on a calcineurin inhibitor-based immunosuppressive regimen. METHODS: The Cochrane Controlled Trials Registry, MEDLINE, and EMBASE were searched for randomized controlled trials of fish oil treatment in kidney transplant recipients on a calcineurin inhibitor-based immunosuppressive regimen. Trials comparing fish oil to both placebo and statins were included. Data were extracted for patient and graft survival, acute rejection, calcineurin inhibitor toxicity, cardiovascular events, adverse effects, compliance, renal function, blood pressure, and lipid profile. Dichotomous outcomes were reported as relative risk and continuous outcome measures as weighted mean differences (WMD), with 95% confidence intervals. RESULTS: Sixteen suitable trials were analyzed. Fish oil treatment was associated with a lower diastolic blood pressure (WMD 4.5 mmHg, P=0.004) and higher high-density lipoprotein (HDL) cholesterol (WMD 0.12 mmol/L, P=0.01) but did not affect the other outcomes. Fishy aftertaste and gastrointestinal upset were common but did not result in significant dropout. Fish oil effects on lipids were not significantly different than low-dose statins. CONCLUSION: There is insufficient evidence from currently available randomized controlled trials to recommend fish oil therapy to improve renal function, rejection rates, and patient or graft survival. Improvements in HDL cholesterol and diastolic blood pressure were too modest to recommend routine use.