The incidence of cancer in a population-based cohort of Canadian heart transplant recipients.

To assess the long-term risk of developing cancer among heart transplant recipients compared to the Canadian general population, we carried out a retrospective cohort study of 1703 patients who received a heart transplant between 1981 and 1998, identified from the Canadian Organ Replacement Register database. Vital status and cancer incidence were determined through record linkage to the Canadian Mortality Database and Canadian Cancer Registry. Cancer incidence rates among heart transplant patients were compared to those of the general population. The observed number of incident cancers was 160 with 58.9 expected in the general population (SIR = 2.7, 95% CI = 2.3, 3.2). The highest ratios were for non-Hodgkin's lymphoma (NHL) (SIR = 22.7, 95% CI = 17.3, 29.3), oral cancer (SIR = 4.3, 95% CI = 2.1, 8.0) and lung cancer (SIR = 2.0, 95% CI = 1.2, 3.0). Compared to the general population, SIRs for NHL were particularly elevated in the first year posttransplant during more recent calendar periods, and among younger patients. Within the heart transplant cohort, overall cancer risks increased with age, and the 15-year cumulative incidence of all cancers was estimated to be 17%. There is an excess of incident cases of cancer among heart transplant recipients. The relative excesses are most marked for NHL, oral and lung cancer.

Reduction in cardiovascular related hospitalization with nocturnal home hemodialysis.

BACKGROUND: Cardiovascular disease remains the leading cause of death among patients with end-stage renal disease (ESRD). Nocturnal home hemodialysis (NHD) (5 - 6 sessions per week; 6 - 8 hours per session) is a novel form of home-based renal replacement therapy, which has been shown to improve several cardiovascular risk factors. The impact of NHD on hospitalization rate has remained unclear. We hypothesized that augmentation of small and middle molecular clearance by NHD would result in a reduction of dialysis related or cardiovascular specific hospitalizations. METHODS AND RESULTS: In this controlled cohort study, we studied 32 NHD patients (age: 43 +/- 2 [mean +/- SEM]) 1 year before and 2 years after conversion to NHD and 42 CHD patients (mean age: 44 +/- 2) (matched for age, dialysis vintage and controlled for comorbidities) during the same time period. The primary outcome was the change in a composite of dialysis or cardiovascular related admissions rate before and after conversion to NHD. Secondary outcomes included changes in all cause hospitalization rate, visits to emergency, reasons and duration of hospitalization and dialysis-related biochemical parameters. During the study period, dialysis or cardiovascular-related admission rate was stable for the CHD control cohort (from 0.48 +/- 0.14 [baseline] to 0.40 +/- 0.12 [end of study] admission per patient year, p = NS). In contrast, conversion to NHD is associated with a decrease in our composite endpoint (from 0.50 +/- 0.15 to 0.17 +/- 0.06 admission per patient year, p = 0.04). Cardiovascular disease (37%) was the principal cause for hospitalization in the control population. In comparison, vascular access related admission was the primary cause of admission for the NHD cohort (56%), p = 0.001. Of the biochemical parameters, NHD is associated with a decrease in plasma phosphate (from 1.7 +/- 0.1 to 1.3 +/- 0.1 mM, p = 0.01) and an improved control of anemia (from 114 +/- 2 to 122 +/- 3 g/l, p = 0.02). CONCLUSION: Conversion to NHD is associated with a decrease in dialysis and cardiovascular-related hospital admission. The clinical and mechanistic relevance in uremic patients of improved phosphate and anemia management requires further examination.

Cancer incidence among Canadian kidney transplant recipients.

A number of studies have observed increased cancer incidence rates among individuals who have received renal transplants. Generally, however, these studies have been limited by relatively small sample sizes, short follow-up intervals or focused on only one cancer site. We conducted a nationwide population-based study of 11,155 patients who underwent kidney transplantation between 1981 and 1998. Incident cancers were identified up to December 31, 1999, through record linkage to the Canadian Cancer Registry. Patterns of cancer incidence in the cohort were compared to the Canadian general population using standardized incidence ratios (SIRs). We examined variations in risk according time since transplantation, year of transplantation and age at transplantation. In our patient population, we observed a total of 778 incident cancers versus 313.2 expected (SIR = 2.5, 95% CI = 2.3-2.7). Site-specific SIRs were highest for cancer of the lip (SIR = 31.3, 95% CI = 23.5-40.8), non-Hodgkin's lymphoma (NHL) (SIR = 8.8, 95% CI = 7.4-10.5), and kidney cancer (SIR = 7.3, 95% CI = 5.7-9.2). SIRs for NHL and cancer of the lip and kidney were highest and among transplant patients. This study confirms previous findings of increased risks of posttransplant cancer. Our findings underscore the need for increased vigilance among kidney transplant recipients for cancers at sites where there are no population-based screening programs in place.

Mortality after kidney transplantation: a comparison between the United States and Canada.

There is a paucity of comparative studies on country-specific outcomes in kidney transplantation. We compared post-transplant mortality among primary, adult, solitary kidney transplant recipients (KTR) from the United States (n = 70 708) and Canada (n = 5773), between January 1, 1991 and December 31, 1998, using data from the Scientific Registry of Transplant Recipients and the Canadian Organ Replacement Register. Multivariable Cox regression revealed higher adjusted post-transplant mortality among U.S. (vs. Canadian) KTR (HR = 1.35 [95% CI 1.24, 1.47; p < 0.005]). Mortality risk in the first post-transplant year was similar in both countries but higher in the United States beyond the first year (HR = 1.49-1.53; p < 0.005). There was no difference in mortality among patients transplanted within 1 year of starting dialysis, but mortality was increased in U.S. (vs. Canadian) patients after 1-2 and 4+ years on dialysis (HR = 1.36-1.66; p < 0.005). Greater mortality was also seen in U.S. patients with diabetes mellitus and/or graft failure. In conclusion, there are considerable differences in the survival of KTR in the United States and Canada. A detailed examination of factors contributing to this variation may yield important insights into improving outcomes for all KTR.

Impact of nocturnal home hemodialysis on anemia management in patients with end-stage renal disease.

AIM: Anemia is adversely associated with poor uremia control and is an established cardiovascular risk factor in patients with end-stage renal disease (ESRD). Nocturnal home hemodialysis (NHD) is a novel form of renal replacement therapy that offers superior clearance of uremic solutes and improvements in several cardiovascular outcome parameters. We conducted a retrospective cohort study to test the hypotheses that augmenting the dose and frequency of dialysis by NHD would improve hemoglobin (Hb) concentrations and decrease requirement of erythropoietin (EPO) in ESRD patients. METHODS: In 63 patients (mean age: 46 +/- 2 years) receiving NHD (mean duration: 2.1 +/- 0.2 years), Hb, EPO dose, iron saturation, ferritin were determined before and at six monthly repeated intervals after conversion to NHD. For comparison, 32 ESRD patients (mean age: 57 +/- 3 years) who remained on self-care conventional hemodialysis (CHD) were also studied. RESULTS: There were no differences in baseline Hb concentrations, iron saturation, ferritin, or EPO dose between the two cohorts. After transfer from CHD to NHD, there were significant improvements in Hb concentrations (from 115 +/- 2 to 122 +/- 3 (6 months) and 124 +/- 2 (12 months) g/l, p = 0.03) despite a fall in EPO requirement (from 10,400 +/- 1400 to 8500 +/- 1300 (6 months) and 7600 +/- 1100 (12 months) U/week, p = 0.03). In contrast, CHD cohort had no change in EPO requirement (from 8300 +/- 1100 to 8100 +/- 1300 (6 months) and 8600 +/- 1000 (12 months) U/week, p > 0.05) or Hb concentrations (from 110 +/- 2 to 115 +/- 3 (6 months) and 115 +/- 2 (12 months), p > 0.05). There was a higher percentage of ESRD patients who did not require EPO in the NHD cohort (24% vs. 9.4%, p = 0.01). Lower Hb concentrations were noted in the CHD cohort despite higher iron saturation (0.25 +/- 0.01 (NHD) vs. 0.33 +/- 0.02 (CHD), p = 0.02) at the end of follow-up. CONCLUSIONS: Enhancing uremic clearance by NHD resulted in a rise in Hb and a fall in EPO requirement.

Trends in CAPD technique failure: Canada, 1981-1997.

OBJECTIVE: Although important enhancements to continuous ambulatory peritoneal dialysis (CAPD) have occurred since its inception, few studies have explicitly evaluated trends over time in CAPD technique failure rates. To assist in quantifying the net benefit of improvements to CAPD for patient outcomes, we examined trends in technique failure rates among Canadian CAPD patients. PATIENTS: Patients initiating renal replacement therapy on CAPD (n = 7110) between 1981 and 1997. MAIN OUTCOME MEASURES: Technique failure (i.e., switch to hemodialysis). RESULTS: Total follow-up was 12,831 patient-years (pt-yr). There were 1976 technique failures, for a crude CAPD failure rate of 154.0/1000 pt-yr. Technique failure rate ratios (RR) estimated using Poisson regression and adjusted for age, gender, race, province, primary renal diagnosis, and follow-up time, were significantly reduced for the 1990-93 [RR = 0.75, 95% confidence interval (CI) = (0.68, 0.83)], 1994-95 [RR = 0.83, CI (0.75, 0.93)], and 1996-97 [RR = 0.78, CI (0.70, 0.87)] calendar periods relative to 1981-89 (RR = 1, reference). Among cause-specific technique failure rates, the greatest improvement was observed for peritonitis-attributable technique failure, with RR = 0.46, CI (0.41, 0.50) for 1990-97 relative to 1981-89. However, rates of technique failure due to inadequate dialysis were significantly elevated for the 1990-97 period [RR = 1.68, CI (1.44, 1.96)]. CONCLUSIONS: The collection of more detailed data on practice patterns would enable future studies to elucidate the cause-and-effect relationship between CAPD descriptors and technique failure, and hence assist in clinical decision-making.

Effect of renal center characteristics on mortality and technique failure on peritoneal dialysis.

BACKGROUND: Recent studies report decreased mortality in patients on peritoneal dialysis (PD) over time, suggesting that advances in PD have resulted in improved patient outcomes. Our investigation sought to assess the effect of renal center characteristics on mortality and technique failure (TF) rates. METHODS: Covariates of interest included center-specific cumulative number of PD patients treated, percentage of patients who initiated dialysis on PD, and academic status. Using data obtained from the Canadian Organ Replacement Register, the 17,900 patients who received PD during the 1981 to 1997 period were studied. Mortality and TF rate ratios (RR) were estimated using Poisson regression, adjusting for age, gender, race, primary renal diagnosis, province, follow-up time, and type of PD. RESULTS: As the cumulative number of PD patients treated increased, covariate-adjusted mortality significantly decreased (P < 0.05); a weaker yet significant association was observed between number of PD patients treated and TF. As the percentage of patients initiating dialysis on PD increased, TF rates decreased significantly. No association was observed between center academic status and PD mortality or TF rates. CONCLUSIONS: These results imply that a center's experience with and degree of specialization toward PD impact strongly on PD outcomes. One hypothesis is that a center's propensity to exploit technical and non-technical advances in PD increases directly with these variables. It is also possible that, through experience, centers become more adept at identifying appropriate patients to receive PD. More detailed research is required to evaluate these hypotheses.

Sex inequality in kidney transplantation rates.

BACKGROUND: Men in the United States undergoing renal replacement therapy are more likely than women to receive a kidney transplant. However, the ability to pay may, in part, be responsible for this finding. OBJECTIVE: To compare adult male and female transplantation rates in a setting in which equal access to medical treatment is assumed. METHODS: Using data from the Canadian Organ Replacement Register, the rate of first transplantations was computed for the 20, 131 men and the 13,458 women aged 20 years or older who initiated renal replacement therapy between January 1, 1981, and December 31, 1996. Poisson regression analysis was used to estimate the male-female transplantation rate ratio, adjusting for age, race, province, calendar period, underlying disease leading to renal failure, and dialytic modality. Actuarial survival methods were used to compare transplantation probability for covariable-matched cohorts of men and women. RESULTS: Men experienced 20% greater covariable-adjusted kidney transplantation rates relative to women (rate ratio, 1.20; 95% confidence interval, 1.13-1.27). The sex disparity was stronger for cadaveric transplants (rate ratio, 1.23) compared with those from living donors (rate ratio, 1.10). The 5-year probability of receiving a transplant was 47% for men and 39% for women within covariable-matched cohorts (P<.001). The sex disparity in transplantation rates increased with increasing age. The sex effect was weaker among whites and Oriental persons (Chinese, Japanese, Vietnamese, Cambodian, Laotian, Filipino, Malaysian, Indonesian, and Korean) and stronger among blacks, Asian Indians (Indian, Pakistani, and Sri Lankan), and North American Indians (aboriginal). CONCLUSION: Since survival probability and quality of life are superior for patients who undergo transplantation relative to those who undergo dialysis, an increased effort should be made to distribute kidneys available for transplantation more equitably by sex among patients undergoing renal replacement therapy.

End-stage renal disease in Canada: prevalence projections to 2005.

BACKGROUND: The incidence and prevalence of end-stage renal disease (ESRD) have increased greatly in Canada over the last 2 decades. Because of the high cost of therapy, predicting numbers of patients who will require dialysis and transplantation is necessary for nephrologists and health care planners. METHODS: The authors projected ESRD incidence rates and therapy-specific prevalence by province to the year 2005 using 1981-1996 data obtained from the Canadian Organ Replacement Register. The model incorporated Poisson regression to project incidence rates, and a Markov model for patient follow-up. RESULTS: Continued large increases in ESRD incidence and prevalence were projected, particularly among people with diabetes mellitus. As of Dec. 31, 1996, there were 17,807 patients receiving renal replacement therapy in Canada. This number was projected to climb to 32,952 by the end of 2005, for a relative increase of 85% and a mean annual increase of 5.8%. The increased prevalence was projected to be greatest for peritoneal dialysis (6.0% annually), followed by hemodialysis (5.9%) and functioning kidney transplant (5.7%). The projected annual increases in prevalence by province ranged from 4.4%, in Saskatchewan, to 7.5%, in Alberta. INTERPRETATION: The projected increases are plausible when one considers that the incidence of ESRD per million population in the United States and other countries far exceeds that in Canada. The authors predict a continued and increasing short-fall in resources to accommodate the expected increased in ESRD prevalence.

Peritoneal dialysis reduces the use of non native fistula access in dialysis programs.

Access problems remain the major difficulty associated with chronic hemodialysis. Despite recent recommendations by the Dialysis Outcomes Quality Initiative (DOQI) that native arteriovenous (AV) fistulae are the optimal form of vascular access, grafts and central catheters are used by many patients. We analyzed our large Canadian regional dialysis program, which has a high prevalence of peritoneal dialysis, to examine the effect of dialysis modality choice on vascular access utilization. Point prevalence data were collected from our program in October 1997, and technique and patient survival data for the period 1990-1996 were analyzed and compared to data for the remainder of Canada from the Canadian Organ Replacement Register. Mortality rate ratios were estimated using a Poisson regression model to correct for comorbidity, age, and end-stage renal disease etiology. Of 141 in-center hemodialysis patients, 91 had an AV fistula, 1 had a polytetrafluoroethylene (PTFE) graft, and 49 were catheter-dependent. The program also included 20 home hemodialysis patients with AV fistulae, and 156 patients on peritoneal dialysis. No mortality risk differences between hemodialysis and peritoneal dialysis are seen in our center, nor are they seen for each modality in comparison with the remainder of Canada. Technique survival for peritoneal dialysis at our center was about 80% at 2 years, significantly greater than for Canada. For the program as a whole, 49% of patients used peritoneal dialysis 35% a native AV fistula, and 15% a central catheter. For Canada and the U.S.A. respectively, the comparable data were: peritoneal dialysis, 32% and 17%; native fistula, 33% and 15%; PTFE, 19% and 41%; and central catheter 16% and 27%. These data suggest that the use of peritoneal dialysis may allow reduced use of non native AV fistula access without mortality penalty.

Comparing mortality rates on CAPD/CCPD and hemodialysis. The Canadian experience: fact or fiction?

OBJECTIVE: To compare mortality rates on hemodialysis (HD) to rates on continuous ambulatory/cyclic peritoneal dialysis (CAPD/CCPD), to contrast our results with those of other recent investigations, and to discuss reasons for discrepancies. DATA SOURCES: Patient-specific data obtained from the Canadian Organ Replacement Register on patients initiating renal replacement therapy (RRT) between 1 January 1990 and 31 December 1995 (n = 14 483). Recent mortality comparisons of CAPD and HD. MAIN OUTCOME MEASURES: Mortality rate ratio (RR) based on "as-treated" (AT) analysis incorporating treatment modality switches and adjusting for age, primary renal diagnosis, and comorbid conditions using Poisson regression. Hazard ratios (HR) were estimated using Cox regression and based on an "intent-to-treat" (ITT) analysis wherein patients were classified based on dialytic modality received on follow-up day 90. RESULTS: Adjusted mortality rates were significantly decreased on CAPD/CCPD relative to HD [RR = 0.73, 95% confidence interval (CI) = (0.69, 0.77)] based on the AT analysis. Most of the protective effect of CAPD/CCPD was concentrated in the first 2 years of follow-up post-RRT initiation. Based on the ITT analysis, the estimated CAPD/ CCPD effect was greatly reduced, with HR = 0.93 (0.87, 0.99). CONCLUSIONS: We provide further evidence that CAPD/CCPD is not an inferior dialytic modality to HD, particularly in the short term. Comparing mortality rates on CAPD/CCPD and HD is inherently difficult due to the potential for bias. Discrepancies between our results and those of previous investigations, and variability in findings among previous studies, relate to differences in clinical and demographic setting, patient populations, study design, statistical methods, and interaction between the dialytic modality effect and various other covariables.

End-stage renal disease projections for Canada to 2005 using Poisson and Markov models.

BACKGROUND: End-stage renal disease (ESRD) incidence and prevalence are increasing in many countries worldwide. Due to the high cost of therapy, predicting future numbers of patients requiring dialysis and transplantation is necessary for health care planners. Projecting therapy-specific chronic disease prevalence is inherently problematic, and examples of suitable models and their application are sparse. When applied, rarely was the adequacy of such models evaluated. METHODS: We describe and illustrate a method for projecting therapy-specific ESRD prevalence in Canada for 1995-2005 using data obtained from the Canadian Organ Replacement Register. The projections combine the Poisson model for incidence rates and a Markov model for patient follow-up. Model adequacy is empirically validated by data-splitting. RESULTS: Large increases in ESRD prevalence are expected in Canada, with an average annual increase of 6.9% projected for 1995-2005. Upon validation, the projection model based on 1981-1987 data was able to predict 1994 prevalence within 1%, while projected therapy-specific prevalences closely approximated those observed. CONCLUSIONS: Therapy-specific ESRD prevalence was successfully projected using Poisson and Markov models. Where multistate prevalence forecasts are required, the method could be augmented for application to various other chronic diseases.

Changes in the demographics and prescription of peritoneal dialysis during the last decade.

Changes in the demographics and prescription of peritoneal dialysis (PD) during the past decade are reviewed using data from the United States and Canada. The number of patients in North America undergoing PD has increased markedly over the past decade, but the percentage of total chronic dialysis patients using the modality has remained relatively stable or decreased slightly during recent years. The average age of the patients undergoing PD has increased, and the percentage with diabetes has also increased. Comorbidity has otherwise remained relatively stable and tends to be significantly less than that in patients undergoing chronic hemodialysis (HD). The proportion of PD patients undergoing automated PD (APD) has increased markedly over the past decade and now includes more than one third of the PD patients in North America. The issue of adequacy of clearance achieved on PD has received a lot of attention over the past decade, and this is now being translated into changes in prescription. Patients undergoing continuous ambulatory PD (CAPD) are being prescribed larger dwell volumes, and more than one quarter use 2.5-L dwells or greater. A small number in the United States are being prescribed more than four exchanges a day, but this practice is more common in Canada. With regard to APD, the proportion of patients doing day dwells is now more than two thirds, and the average cycler dwell volumes have also increased. There are no baseline clearance data from a decade ago for comparative purposes, but it appears that clearances have increased in recent years. In general, more than 70% of the patients are achieving recommended clearance targets at the initiation of PD but, among prevalent US patients, the percentage achieving targets is in the range of 40% to 45%, reflecting a loss of residual renal function. In Canada, 60% to 70% of prevalent patients are achieving these targets. PD is a rapidly changing therapy at present. There have been dramatic and impressive improvements in prescription practices, but they need to change further if a higher proportion of patients is to achieve recommended clearance targets.

The Canadian Organ Replacement Register on renal replacement therapy.

This report describes the demography, clinical characteristics, and outcomes for patients receiving renal replacement therapy (RRT) in Canada. Results are based on registered patients initiating RRT during the 1981-85 period using data obtained from the Canadian Organ Replacement Register (CORR).

Hemodialysis versus peritoneal dialysis: a comparison of adjusted mortality rates.

Although kidney transplantation is the preferred treatment method for patients with ESRD, most patients are placed on dialysis either while awaiting transplantation or as their only therapy. The question of which dialytic method provides the best patient survival remains unresolved. Survival analyses comparing hemodialysis and continuous ambulatory peritoneal dialysis/continuous cyclic peritoneal dialysis (CAPD/CCPD), a newer and less costly dialytic modality, have yielded conflicting results. Using data obtained from the Canadian Organ Replacement Register, we compared mortality rates between hemodialysis and CAPD/CCPD among 11,970 ESRD patients who initiated treatment between 1990 and 1994 and were followed-up for a maximum of 5 years. Factors controlled for include age, primary renal diagnosis, center size, and predialysis comorbid conditions. The mortality rate ratio (RR) for CAPD/CCPD relative to hemodialysis, as estimated by Poisson regression, was 0.73 (95% confidence interval: 0.68 to 0.78). No such relationship was found when an intent-to-treat Cox regression model was fit. Decreased covariable-adjusted mortality for CAPD/CCPD held within all subgroups defined by age and diabetes status, although the RRs increased with age and diabetes prevalence. The increased mortality on hemodialysis compared with CAPD/CCPD was concentrated in the first 2 years of follow-up. Although continuous peritoneal dialysis was associated with significantly lower mortality rates relative to hemodialysis after adjusting for known prognostic factors, the potential impact of unmeasured patient characteristics must be considered. Notwithstanding, we present evidence that CAPD/CCPD, a newer and less costly method of renal replacement therapy, is not associated with increased mortality rates relative to hemodialysis.

Image-guided insertion of the Uldall tunneled hemodialysis catheter: technical success and clinical follow-up.

PURPOSE: To evaluate the technical success, complication rates, and survival time of the Uldall double-lumen catheter placed by interventional radiologists in patients presenting to a hemodialysis clinic. MATERIALS AND METHODS: Patients eligible for this study included those with end-stage renal disease (ESRD) who had failed peripheral vascular access or who were awaiting access at a hemodialysis unit between June 1993 and March 1996. All catheters were placed under fluoroscopic and ultrasound guidance in the angiography suite. RESULTS: Attempts were made to insert 130 catheters into jugular veins in a consecutive series of 61 patients with ESRD. The accumulated catheter experience in this cohort was 15,380 days and the median survival time was 141 days (95% confidence interval [CI]; 116 days-166 days). One hundred twenty-one catheters (93%) were successfully inserted, mainly (94%) into the internal jugular vein. Excellent dialysis blood flow rate was obtained-on average 365 mL/min (95% CI; 350-379 mL/min). The overall infection rate, including exit site (n = 13), sepsis (n = 19), and clavicular osteomyelitis (n = 1), was 2.1 episodes per 1,000 catheter days. CONCLUSIONS: This catheter is recommended for acute and longer term hemodialysis for patients without peripheral vascular access. It can be inserted percutaneously, the same internal jugular vein can be used repeatedly with few complications and good blood flow, and the technique can be easily learned by any experienced angiographer.

The Canadian Organ Replacement Register.

The analyses presented in this chapter are a subset of the yearly audit of organ donation and transplantation in Canada published in the CORR Annual Report. They represent the collaborative efforts and the voluntary contributions of many of the transplant physicians, surgeons, nurses and coordinators in Canada. In Canada, organ donation has remained static at approximately 14 per million population. Despite many local and provincial as well as corporate initiatives, this rate is approximately half the current rate in many regions of the U.S.A. and Spain. The modest increases in transplant activity represent an increase in the use of living donors, reassessment of the traditional donor risk factors (including age) and expansion of the potential donors for each organ. Analysis of the renal transplant activity has determined that the likelihood of being transplanted during the first year on the list was less than 40%. A graft loss rate of 4% per year after the first year was observed for a cadaveric kidney, compared with graft loss rates of 3% and 2% per year for living-related and living-unrelated donor kidneys, respectively. Cox regressional analysis identified that the major determinants of patient survival were the transplant year, the region where the transplant was performed, the presence of diabetes, the recipient's age, and whether the kidney was from a living donor. Liver transplantation has increased each year at the transplant centers in Vancouver, Edmonton, London, Toronto, Montreal, and Halifax. Patient and graft survival rates have improved since 1985 and the most significant determinant of patient survival following transplantation was the patient's medical status at the time of transplantation. Living-related liver donor transplant programs have begun in London and Toronto. Pancreas transplantation remains limited across Canada, but with the development of new pancreas programs in Toronto and Halifax, an increase in the availability of this therapy for Type 1 diabetics is anticipated. Heart transplantation has recovered from a decline in 1991-1992 to approximately 6 hearts per million population. There has been a trend towards better one- and 3-year patient survival rates since 1985. With the development of a lung transplantation program in Winnipeg, lung transplantation has increased. This likely reflects increased utilization of the available donor lungs. A particular increase in double-lung transplants was noted.

New and prevalent patients with end-stage renal disease in Canada. A portrait of the year 2000.

The number of patients initiating treatment for end-stage renal disease (ESRD) has increased dramatically in Canada and other countries. To assist healthcare planners, the prevalence of ESRD in Canada has been projected to the year 2000 using a Markov modelling technique. Significant increases in ESRD are expected in Canada during the next decade, particularly among the elderly and diabetic populations: estimated increases in prevalence rates of ESRD between 1992 and the year 2000 were 78% and 154% for non diabetic and diabetic populations respectively. These expected increases did not differ significantly between the treatment groups, except among patients with diabetes, in whom projected increases in the prevalence of functioning transplant was smaller than for hemodialysis or peritoneal dialysis. Because the current Canadian prevalence rates are lower than those of some other countries, such as the United States and Japan, these expected trends in prevalence appear reasonable, and illustrate the growing healthcare needs of the ESRD population in Canada during the next decade.

A comparison of rabbit antithymocyte serum and OKT3 as prophylaxis against renal allograft rejection.

A total 166 first cadaveric renal allograft recipients were randomly assigned to receive either rabbit antithymocyte serum (RATS) (n = 83) or OKT3 (n = 83) for 10 to 14 days after transplant as prophylaxis against rejection. Both groups were similar with respect to age, sex, donor age, diabetes, time on dialysis, panel-reactive antibody, HLA matching, and transfusion before transplantation. All patients were followed for 1 year after transplantation. A comparison of the rejection rates between the 2 groups of patients showed that patients receiving OKT3 had a rate of first rejection 1.87 times higher than those receiving RATS (95% confidence interval 1.18-2.8, P = 0.007). Twenty-five steroid-resistant rejections occurred in OKT3-treated patients as compared with 12 in the RATS-treated group (P < 0.05). There was no significant difference in early or late renal function between the 2 groups of patients. Actuarial 1-year graft survival for the RATS group was 78% and for the OKT3 group, 80.7% (P = NS). Actuarial 1-year patient survival was similar: 89.5% in the RATS group and 94.6% in the OKT3 group (P = NS). Total hospitalization time was 29.8 +/- 19.9 days for RATS vs. 39.5 +/- 22.1 days for those treated with OKT3 (P < 0.006). A number of infections were observed but there were no significant differences between the groups. We conclude that RATS provides better prophylaxis than OKT3 in first cadaveric renal transplants because it is associated with fewer rejection episodes, less hospitalization, and no additional morbidity or mortality.