Characteristics and Outcomes of Patients With Systemic Sclerosis (Scleroderma) Requiring Renal Replacement Therapy in Europe: Results From the ERA-EDTA Registry.

RATIONALE & OBJECTIVE: Data for outcomes of patients with end-stage renal disease (ESRD) secondary to systemic sclerosis (scleroderma) requiring renal replacement therapy (RRT) are limited. We examined the incidence and prevalence of ESRD due to scleroderma in Europe and the outcomes among these patients following initiation of RRT. STUDY DESIGN: Registry study of incidence and prevalence and a matched cohort study of clinical outcomes. SETTING & PARTICIPANTS: Patients represented in any of 19 renal registries that provided data to the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry between 2002 and 2013. PREDICTOR: Scleroderma as the identified cause of ESRD. OUTCOMES: Incidence and prevalence of ESRD from scleroderma. Recovery from RRT dependence, patient survival after ESRD, and graft survival after kidney transplantation. ANALYTICAL APPROACH: Incidence and prevalence were calculated using population data from the European Union and standardized to population characteristics in 2005. Patient and graft survival were compared with 2 age- and sex-matched control groups without scleroderma: (1) diabetes mellitus as the cause of ESRD and (2) conditions other than diabetes mellitus as the cause of ESRD. Survival analyses were performed using Kaplan-Meier analysis and Cox regression. RESULTS: 342 patients with scleroderma (0.14% of all incident RRT patients) were included. Between 2002 and 2013, the range of adjusted annual incidence and prevalence rates of RRT for ESRD due to scleroderma were 0.11 to 0.26 and 0.73 to 0.95 per million population, respectively. Recovery of independent kidney function was greatest in the scleroderma group (7.6% vs 0.7% in diabetes mellitus and 2.0% in other primary kidney diseases control group patients, both P<0.001), though time required to achieve recovery was longer. The 5-year survival probability from day 91 of RRT among patients with scleroderma was 38.9% (95% CI, 32.0%-45.8%), whereas 5-year posttransplantation patient survival and 5-year allograft survival were 88.2% (95% CI, 75.3%-94.6%) and 72.4% (95% CI, 55.0%-84.0%), respectively. Adjusted mortality from day 91 on RRT was higher among patients with scleroderma than observed in both control groups (HRs of 1.25 [95% CI, 1.05-1.48] and 2.00 [95% CI, 1.69-2.39]). In contrast, patient and graft survival after kidney transplantation did not differ between patients with scleroderma and control groups. LIMITATIONS: No data for extrarenal manifestations, treatment, or recurrence. CONCLUSIONS: Survival of patients with scleroderma who receive dialysis for more than 90 days was worse than for those with other causes of ESRD. Patient survival after transplantation was similar to that observed among patients with ESRD due to other conditions. Patients with scleroderma had a higher rate of recovery from RRT dependence than controls.

Factors associating with differences in the incidence of renal replacement therapy among elderly: data from the ERA-EDTA Registry.

Background: The incidence of renal replacement therapy (RRT) in the general population ≥75 years of age varies considerably between countries and regions in Europe. Our aim was to study characteristics and survival of elderly RRT patients and to find explanations for differences in RRT incidence. Methods: Patients ≥75 years of age at the onset of RRT in 2010-2013 from 29 national or regional registries providing data to the European Renal Association-European Dialysis and Transplant Association Registry were included. Chi-square and Mann-Whitney U tests were used to assess variation in patient characteristics and linear regression was used to study the association between RRT incidence and various factors. Kaplan-Meier curves and Cox regression were employed for survival analyses. Results: The mean annual incidence of RRT in the age group ≥75 years of age ranged from 157 to 924 per million age-related population. The median age at the start of RRT was higher and comorbidities were less common in areas with higher RRT incidence, but overall the association between patient characteristics and RRT incidence was weak. The unadjusted survival was lower in high-incidence areas due to an older age at onset of RRT, but the adjusted survival was similar [relative risk 1.00 (95% confidence interval, 0.97-1.03)] in patients from low- and high-incidence areas. Conclusions: Variation in the incidence of RRT among the elderly across European countries and regions is remarkable and could not be explained by the available data. However, the survival of patients in low- and high-incidence areas was remarkably similar.

Access to kidney transplantation in European adults aged 75-84 years and related outcomes: an analysis of the European Renal Association-European Dialysis and Transplant Association Registry.

To what extent access to, and allocation of kidney transplants and survival outcomes in patients aged ≥75 years have changed over time in Europe is unclear. We included patients aged ≥75-84 years (termed older adults) receiving renal replacement therapy in thirteen European countries between 2005 and 2014. Country differences and time trends in access to, and allocation of kidney transplants were examined. Survival outcomes were determined by Cox regression analyses. Between 2005 and 2014, 1392 older adult patients received 1406 transplants. Access to kidney transplantation varied from ~0% (Slovenia, Greece and Denmark) to ~4% (Norway and various Spanish regions) of all older adult dialysis patients, and overall increased from 0.3% (2005) to 0.9% (2014). Allocation of kidney transplants to older adults overall increased from 0.8% (2005) to 3.2% (2014). Seven-year unadjusted patient and graft survival probabilities were 49.1% (95% confidence interval, 95% CI: 43.6; 54.4) and 41.7% (95% CI: 36.5; 46.8), respectively, with a temporal trend towards improved survival outcomes. In conclusion, in the European dialysis population aged ≥75-84 years access to kidney transplantation is low, and allocation of kidney transplants remains a rare event. Though both are increasing with time and vary considerably between countries. The trend towards improved survival outcomes is encouraging. This information can aid informed decision-making regarding treatment options.

Changes in co-morbidity pattern in patients starting renal replacement therapy in Europe-data from the ERA-EDTA Registry.

Background: Patients starting renal replacement therapy (RRT) for end-stage renal disease often present with one or more co-morbidities. This study explored the prevalence of co-morbidities in patients who started RRT in Europe during the period from 2005 to 2014. Methods: Using data from patients aged 20 years or older from all 11 national or regional registries providing co-morbidity data to the European Renal Association - European Dialysis and Transplant Association Registry, we examined the prevalence of the following co-morbidities: diabetes mellitus (DM) (primary renal disease and/or co-morbidity), ischaemic heart disease (IHD), congestive heart failure (CHF), peripheral vascular disease (PVD), cerebrovascular disease (CVD) and malignancy. Results: Overall, 70% of 7578 patients who initiated RRT in 2014 presented with at least one co-morbidity: 39.0% presented with DM, 25.0% with IHD, 22.3% with CHF, 17.7% with PVD, 16.4% with malignancy and 15.5% with CVD. These percentages differed substantially between countries. Co-morbidities were more common in men than in women, in older patients than in younger patients, and in patients on haemodialysis at Day 91 when compared with patients on peritoneal dialysis. Between 2005 and 2014 the prevalence of DM and malignancy increased over time, whereas the prevalence of IHD and PVD declined. Conclusions: More than two-thirds of patients initiating RRT in Europe have at least one co-morbidity. With the rising age at the start of RRT over the last decade, there have been changes in the co-morbidity pattern: the prevalence of cardiovascular co-morbidities decreased, while the prevalence of DM and malignancy increased.

Renal replacement therapy in Europe: a summary of the 2011 ERA-EDTA Registry Annual Report.

BACKGROUND: This article provides a summary of the 2011 ERA-EDTA Registry Annual Report (available at www.era-edta-reg.org). METHODS: Data on renal replacement therapy (RRT) for end-stage renal disease (ESRD) from national and regional renal registries in 30 countries in Europe and bordering the Mediterranean Sea were used. From 27 registries, individual patient data were received, whereas 17 registries contributed data in aggregated form. We present the incidence and prevalence of RRT, and renal transplant rates in 2011. In addition, survival probabilities and expected remaining lifetimes were calculated for those registries providing individual patient data. RESULTS: The overall unadjusted incidence rate of RRT in 2011 among all registries reporting to the ERA-EDTA Registry was 117 per million population (pmp) (n = 71.631). Incidence rates varied from 24 pmp in Ukraine to 238 pmp in Turkey. The overall unadjusted prevalence of RRT for ESRD on 31 December 2011 was 692 pmp (n = 425 824). The highest prevalence was reported by Portugal (1662 pmp) and the lowest by Ukraine (131 pmp). Among all registries, a total of 22 814 renal transplantations were performed (37 pmp). The highest overall transplant rate was reported from Spain, Cantabria (81 pmp), whereas the highest rate of living donor transplants was reported from Turkey (39 pmp). For patients who started RRT between 2002 and 2006, the unadjusted 5-year patient survival on RRT was 46.8% [95% confidence interval (CI) 46.6-47.0], and on dialysis 39.3% (95% CI 39.2-39.4). The unadjusted 5-year patient survival after the first renal transplantation performed between 2002 and 2006 was 86.7% (95% CI 86.2-87.2) for kidneys from deceased donors and 94.3% (95% CI 93.6-95.0) for kidneys from living donors.

Polypharmacy patterns: unravelling systematic associations between prescribed medications.

OBJECTIVES: The aim of this study was to demonstrate the existence of systematic associations in drug prescription that lead to the establishment of patterns of polypharmacy, and the clinical interpretation of the associations found in each pattern. METHODS: A cross-sectional study was conducted based on information obtained from electronic medical records and the primary care pharmacy database in 2008. An exploratory factor analysis of drug dispensing information regarding 79,089 adult patients was performed to identify the patterns of polypharmacy. The analysis was stratified by age and sex. RESULTS: Seven patterns of polypharmacy were identified, which may be classified depending on the type of disease they are intended to treat: cardiovascular, depression-anxiety, acute respiratory infection (ARI), chronic obstructive pulmonary disease (COPD), rhinitis-asthma, pain, and menopause. Some of these patterns revealed a clear clinical consistency and included drugs that are prescribed together for the same clinical indication (i.e., ARI and COPD patterns). Other patterns were more complex but also clinically consistent: in the cardiovascular pattern, drugs for the treatment of known risk factors-such as hypertension or dyslipidemia-were combined with other medications for the treatment of diabetes or established cardiovascular pathology (e.g., antiplatelet agents). Almost all of the patterns included drugs for preventing or treating potential side effects of other drugs in the same pattern. CONCLUSIONS: The present study demonstrated the existence of non-random associations in drug prescription, resulting in patterns of polypharmacy that are sound from the pharmacological and clinical viewpoints and that exist in a significant proportion of the population. This finding necessitates future longitudinal studies to confirm some of the proposed causal associations. The information discovered would further the development and/or adaptation of clinical patient guidelines to patients with multimorbidity who are taking multiple drugs.

[Predictive value of the quality of life questionnaire in the elderly]. / Validez predictiva de mortalidad del cuestionario de calidad de vida en ancianos.

OBJECTIVE: To evaluate the predictive value of the quality of life (QOL) questionnaire at 8 years and analyse which of its 5 dimensions better predict adverse results in health. DESIGN: Descriptive, longitudinal, and retrospective study. SETTING: Three basic health areas in Cuenca province, Spain. PARTICIPANTS: We randomly selected 519 subjects over 64 years, taking addresses in which more than 1 person over 64 years resided as a sample marker. MAIN MEASUREMENTS: The QOL questionnaire was used to evaluate the quality of life of the subjects in 1994 and in 2002. Main results. Between 1994 and 2002, 25% of the participants died, 2.6% were institutionalised and there 3.6% losses. The QOL questionnaire has a mortality predictive capacity at 8 years, the cut off point of its global index being situated around 13 points. The sensitivity of the model is poor (41.5%), with a high specificity (93.5%) and a good classification percentage of 80.3%. The positive and negative probability ratios were 6.36 and 0.62, respectively. Using a Cox regression model, it is seen that of the 5 dimensions of the QOL test, activities of daily living show a relationship with mortality (risk ratio or OR=1.3; 95% confiance interval [CI], 1.049-1.611), mental health (OR=1.048; 95% CI, 1.054-1.620), and economic resources (OR=0.806; 95% CI, 0.648-1.003). CONCLUSIONS: The QOL questionnaire has a mortality predictive capacity at 8 years.

Validez predictiva de mortalidad del cuestionario de calidad de vida en ancianos / Predictive value of the quality of life questionnaire in the elderly

Objetivo. Evaluar la validez predictiva del cuestionario calidad de vida en ancianos (CVA) a 8 años y analizar cuál o cuáles de sus 5 dimensiones predicen mejor los resultados adversos en salud. Diseño. Estudio descriptivo, longitudinal y retrospectivo. Emplazamiento. Tres zonas básicas de salud de la provincia de Cuenca. Participantes. Se incluyeron 519 individuos mayores de 64 años seleccionados aleatoriamente tomando como marco muestral los domicilios en los que residía al menos una persona mayor de 64 años. Mediciones principales. Se utilizó el cuestionario CVA para evaluar la calidad de vida de los individuos en 1994 y en 2002. Resultados principales. Entre 1994 y 2002, falleció el 25% de los participantes, fue ingresado en instituciones un 2,6% y se produjo un 3,6% de pérdidas. El cuestionario CVA tiene capacidad predictiva de mortalidad a 8 años, y el punto de corte de su índice global se sitúa en torno a los 13 puntos. La sensibilidad del modelo es pobre (41,5%), con una especificidad alta (93,5%) y un porcentaje de buenas clasificaciones del 80,3%. Las razones de probabilidad positiva y negativa fueron 6,36 y 0,62, respectivamente. Mediante un modelo de regresión de Cox se aprecia que de las 5 dimensiones del test CVA tienen relación con la mortalidad las actividades de la vida diaria (razón de riesgos o HR = 1,3; intervalo de confianza [IC] del 95%, 1,049-1,611), la salud mental (HR = 1,048; IC del 95%, 1,054-1,620) y los recursos económicos (HR = 0,806; IC del 95%, 0,648-1,003). Conclusiones. El cuestionario CVA posee capacidad para predecir la mortalidad a 8 años

Objective. To evaluate the predictive value of the quality of life (QOL) questionnaire at 8 years and analyse which of its 5 dimensions better predict adverse results in health. Design. Descriptive, longitudinal, and retrospective study. Setting. Three basic health areas in Cuenca province, Spain. Participants. We randomly selected 519 subjects over 64 years, taking addresses in which more than 1 person over 64 years resided as a sample marker. Main measurements. The QOL questionnaire was used to evaluate the quality of life of the subjects in 1994 and in 2002. Main results. Between 1994 and 2002, 25% of the participants died, 2.6% were institutionalised and there 3.6% losses. The QOL questionnaire has a mortality predictive capacity at 8 years, the cut off point of its global index being situated around 13 points. The sensitivity of the model is poor (41.5%), with a high specificity (93.5%) and a good classification percentage of 80.3%. The positive and negative probability ratios were 6.36 and 0.62, respectively. Using a Cox regression model, it is seen that of the 5 dimensions of the QOL test, activities of daily living show a relationship with mortality (risk ratio or OR=1.3; 95% confiance interval [CI], 1.049-1.611), mental health (OR=1.048; 95% CI, 1.054-1.620), and economic resources (OR=0.806; 95% CI, 0.648-1.003). Conclusions. The QOL questionnaire has a mortality predictive capacity at 8 years