Anirudh Rao

UK Renal Registry 17th Annual Report: Chapter 2 UK Renal Replacement Therapy Prevalence in 2013: National and Centre-specific Analyses

INTRODUCTION This chapter describes the characteristics of adult patients on renal replacement therapy (RRT) in the UK in 2013. METHODS Data were electronically collected from all 71 renal centres within the UK. A series of cross sectional and longitudinal analyses were performed to describe the demographics of prevalent RRT patients in 2013 at centre and national level. RESULTS There were 56,940 adult patients receiving RRT in the UK on 31st December 2013. The UK adult prevalence of RRT was 888 pmp which represented an annual increase of 4%,with transplantation the most common treatment modality(52%). There was variation between centres, Clinical Commissioning Groups and Health Boards. The number of patients increased by 1.2% for haemodialysis (HD) and 7.1% for functioning transplant but decreased 3.3% for peritoneal dialysis (PD). The number of patients receiving home HD has increased by 3% since 2012. Median RRT vintage for patients on HD was 3.4 years, PD 1.7 years and for transplant, 10.1 years. The median age of prevalent patients was 58 years (HD 67 years, PD 64 years, transplant 53 years)compared to 55 years in 2000. For all ages the prevalence rate in men exceeded that in women. The most common recorded renal diagnosis was glomerulonephritis (biopsy proven/not biopsy proven) (19%). CONCLUSIONS The HD and transplant population continued to expand; but the prevalent PD population continues to decline. There were national, regional and centre level variations in prevalence rates. This has continued implications for service planning and ensuring equity of care for RRT patients.

UK Renal Registry 15th annual report: Chapter 1 UK RRT incidence in 2011: national and centre-specific analyses.

Introduction: This chapter describes the characteristics of adult patients starting renal replacement therapy (RRT) in the UK in 2011 and the incidence rates for RRT in Primary Care Trusts and Health Boards (PCT/HBs) in the UK. Methods: Basic demographic and clinical characteristics are reported on patients starting RRT at all UK renal centres. Presentation time, defined as time between first being seen by a nephrologist and start of RRT, was also studied. Age and gender standardised ratios for incidence rates in PCT/HBs were also calculated. Results: In 2011, the incidence rate in the UK was similar to 2010 at 108 per million population (pmp). There were wide variations between PCT/HBs in standardised incidence ratios. For the 2006-2011 incident cohort analysis the range was 0.42 to 2.52 (IQR 0.85, 1.20). The median age of all incident patients was 64.9 years (IQR 50.9, 75.1). For transplant centres this was 63.8 years (IQR 49.5, 74.3) and for non-transplanting centres 66.2 years (IQR 52.4, 76.0). The median age for non-Whites was 58.4 years. Diabetic renal disease remained the single most common cause of renal failure (25%). By 90 days, 67.1% of patients were on haemodialysis, 19.2% on perito- neal dialysis, 7.8% had had a transplant and 5.8% had died or stopped treatment. This is the second year in a row that the percentage on peritoneal dialysis has increased and, in 2011, this was most notable in the 65-74 age group. There was a lot of variability in use of PD with some centres having over twice the average percentage on PD. The mean eGFR at the start of RRT was 8.7 ml/min/1.73 m2 similar to the previous four years. Late presentation (<90 days) fell from 23.9% in 2006 to 19.6% in 2011. There was no relationship between social deprivation and presentation pattern. Conclusions: Incidence rates have plateaued in England over the last six years. There has been an increase in the percentage of new patients still on RRT at 90 days after starting who were on PD at 90 days (19.2 to 20.4%).

UK Renal Registry 16th annual report: chapter 5 comorbidities and current smoking status amongst patients starting renal replacement therapy in England, Wales and Northern Ireland from 2011 to 2012.

Introduction: Comorbidities are significant predictors of mortality and other adverse outcomes. Case-mix adjustment is integral to quality reporting, risk adjustment in clinical research, resource allocation and management of patients with comorbid conditions in day to day practice such as dialysis access formation and transplant wait-listing. This study describes the comorbidity data submitted to the UK Renal Registry (UKRR) in incident renal replacement therapy (RRT) patients and examines the association between these comorbidities and early mortality. Methods: Incident patients reported to the UKRR with comorbidity data in 2011 and 2012 (n = 7,085) were included in analyses exploring the association of comorbidities with patient demographics and treatment modality. For analyses examining the association between comorbidities and survival, adult patients starting RRT between 2007 and 2012 in centres reporting to the UKRR with comorbidity data were included. The relationship between comorbidities and mortality at 90 days and one year after 90 days from start of RRT were explored using Cox regression. Results: Completeness of comorbidity data was 55% in 2012 compared with 56% in 2007. Of patients with data, 52.9% had one or more comorbidities. Diabetes mellitus and ischaemic heart disease were the most common conditions, observed in 35% and 19% of patients respectively. Fourteen percent of incident RRT patients in the 2-year period were recorded as current smokers. The prevalence of comorbidity increased with increasing age across all ethnic groups. In multivariable survival analysis, malignancy and liver disease were strong independent predictors of poor survival at 1-year after 90 days from the start of RRT in patients <65 years. Conclusions: Continuing efforts from renal centres to improve data capture in addition to the use of data linkage and statistical techniques such as multiple imputation by the UKRR are likely to lead to enhanced case mix adjustment in the future.

UK Renal Registry 16th Annual Report: Chapter 10 Haemoglobin, Ferritin and Erythropoietin amongst UK Adult Dialysis Patients in 2012: National and Centre-specific Analyses

Background: The UK Renal Association (RA) and National Institute for Health and Care Excellence (NICE) have published Clinical Practice Guidelines which include recommendations for management of anaemia in established renal failure. Aims: To determine the extent to which the guidelines for anaemia management are met in the UK. Methods: Quarterly data were obtained for haemoglobin (Hb) and factors that influence Hb from renal centres in England, Wales, Northern Ireland (E, W, NI) and the Scottish Renal Registry for the incident and prevalent renal replacement therapy (RRT) cohorts for 2011. Results: In the UK, in 2011 51% of patients commenced dialysis therapy with Hb ≥10.0 g/dl (median Hb 10 g/dl). Of patients in the early presentation group, 55% started dialysis with Hb ≥10.0 g/dl whilst 37% of patients presenting late started dialysis with Hb ≥10.0 g/dl. The UK median Hb of haemodialysis (HD) patients was 11.2 g/dl with an inter-quartile range (IQR) of 10.3-12.1 g/dl. Of UK HD patients, 82% had Hb ≥10.0 g/dl. The median Hb of peritoneal dialysis (PD) patients in the UK was 11.4 g/dl (IQR 10.5-12.3 g/dl). Of UK PD patients, 85% had Hb ≥10.0 g/dl. The median ferritin in HD patients in the UK was 436 mg/L (IQR 292-625) and 96% of HD patients had a ferritin ≥100 mg/ L. In EW&NI the median ferritin in PD patients was 273 mg/ L (IQR 153-446) with 86% of PD patients having a ferritin ≥100 mg/L. In EW&NI the mean erythropoietin stimulating agent (ESA) dose was higher for HD than PD patients (8,740 vs. 6,624 IU/week). Conclusions: Prevalent HD and PD patients had 56% and 53% respectively within the Hb ≥10 and ≤12 g/dl target.

UK Renal Registry 18th Annual Report 2015

The UK Renal Registry (UKRR) continues to provide a national source of NHS healthcare data on patients dependent on renal replacement therapy (RRT) across the four nations. Using electronic reporting and substantial integration across the 71 adult and 13 paediatric renal centres independent audit and analysis of dialysis and transplant activity and care across the UK is provided. The UKRR is part of the UK Renal Association and is funded directly by participating renal centres through an annual capitation fee per patient per annum, currently £19 or 0.01% of annual RRT running costs. The UKRR remains relatively unique amongst renal registries in publishing both centre-specific analyses of indicators of quality of care, such as haemoglobin and also ageadjusted survival statistics for each renal centre [1].

UK Renal Registry 18th Annual Report: Chapter 11 2014 Multisite Dialysis Access Audit in England, Northern Ireland and Wales and 2013 PD One Year Follow-up: National and Centre-specific Analyses.

Introduction: Dialysis access should be timely, minimise complications and maintain functionality. Good functional access is required for renal replacement therapy (RRT) to be successful. The aim of the combined vascular and peritoneal dialysis access audit was to examine practice patterns with respect to dialysis access and highlight variations in practice between renal centres. Methods: The UK Renal Registry collected centre-specific information on vascular and peritoneal access outcome measures including patient demographics, dialysis access type (at start of dialysis and three months after start of dialysis), surgical assessment and access functionality. The combined access audit covered incident haemodialysis (HD) and peritoneal dialysis (PD) patients in 2012 from England, Northern Ireland and Wales. Centres who had reported data on incident PD patients for the previous audit in 2011 were additionally asked to provide one year follow up data for this group. Results: Fifty-one centres in England, Wales and Northern Ireland (representing 82% of all centres) returned data on first access from 3,720 incident HD patients and 1,018 incident PD patients. A strong relationship was seen between surgical assessment and the likelihood of starting HD with an arteriovenous fistula (AVF). Type of first access was related to the length of time known to renal services with higher numbers of AVFs and PD catheters used in patients known to renal services for at least one year. Three month and one year outcomes of HD and PD access were poorly reported. Conclusions: This audit provides information on important patient related outcome measures with the potential to lead to an improvement in access provision. This represents an important advance, however data collection remains suboptimal. There is wide practice variation across the England, Wales and Northern Ireland in provision of both HD and PD access which requires further exploration.

Quality of Reporting and Study Design of CKD Cohort Studies Assessing Mortality in the Elderly Before and After STROBE: A Systematic Review

Background The STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) statement was published in October 2007 to improve quality of reporting of observational studies. The aim of this review was to assess the impact of the STROBE statement on observational study reporting and study design quality in the nephrology literature. Study Design Systematic literature review. Setting & Population European and North American, Pre-dialysis Chronic Kidney Disease (CKD) cohort studies. Selection Criteria for Studies Studies assessing the association between CKD and mortality in the elderly (>65 years) published from 1st January 2002 to 31st December 2013 were included, following systematic searching of MEDLINE & EMBASE. Predictor Time period before and after the publication of the STROBE statement. Outcome Quality of study reporting using the STROBE statement and quality of study design using the Newcastle Ottawa Scale (NOS), Scottish Intercollegiate Guidelines Network (SIGN) and Critical Appraisal Skills Programme (CASP) tools. Results 37 papers (11 Pre & 26 Post STROBE) were identified from 3621 potential articles. Only four of the 22 STROBE items and their sub-criteria (objectives reporting, choice of quantitative groups and description of and carrying out sensitivity analysis) showed improvements, with the majority of items showing little change between the period before and after publication of the STROBE statement. Pre- and post-period analysis revealed a Manuscript STROBE score increase (median score 77.8% (Inter-quartile range [IQR], 64.7–82.0) vs 83% (IQR, 78.4–84.9, p = 0.05). There was no change in quality of study design with identical median scores in the two periods for NOS (Manuscript NOS score 88.9), SIGN (Manuscript SIGN score 83.3) and CASP (Manuscript CASP score 91.7) tools. Limitations Only 37 Studies from Europe and North America were included from one medical specialty. Assessment of study design largely reliant on good reporting. Conclusions This study highlights continuing deficiencies in the reporting of STROBE items and their sub-criteria in cohort studies in nephrology. There was weak evidence of improvement in the overall reporting quality, with no improvement in methodological quality of CKD cohort studies between the period before and after publication of the STROBE statement.

UK Renal Registry 17th Annual Report: Appendix B Definitions and Analysis Criteria

The take-on population is defined as all patients over 18 who started renal replacement therapy (RRT) at UK renal centres and did not have a recovery lasting more than 90 days within 90 days of starting RRT. The treatment timeline is used to define take-on patients as follows. If a patient has timeline entries from more than one centre then these are all combined and sorted by date. Then, the first treatment entry gives the first date of when they received RRT. This is defined as a ‘start date’. However, in the following situations there is evidence that the patient was already receiving RRT before this ‘start date’ and these people are not classed as takeon patients:

UK Renal Registry 15th Annual Report: Appendix A The UK Renal Registry Statement of Purpose

1. Executive summary 2. Introduction 3. Statement of intent 4. Relationships of the UK Renal Registry 5. The role of the UK Renal Registry for patients 6. The role of the UK Renal Registry for nephrologists 7. The role of the UK Renal Registry for Trust managers 8. The role of the UK Renal Registry for commissioning agencies 9. The role of the UK Renal Registry in national quality assurance schemes 10. References and websites

UK Renal Registry 17th Annual Report: Chapter 7 Haemoglobin, Ferritin and Erythropoietin amongst UK Adult Dialysis Patients in 2013: National and Centre-specific Analyses

BACKGROUND The diagnosis and management of anaemia in chronic kidney disease and the standards to be achieved have been detailed in the UK Renal Association Anaemia of CKD guidelines. AIMS To determine the attainment of standards for anaemia management in the UK. METHODS Quarterly data were obtained for haemoglobin (Hb) and factors that influence Hb from renal centres in England,Wales, Northern Ireland (EW&NI) and the Scottish Renal Registry for the incident and prevalent renal replacement therapy (RRT) cohorts for 2013. RESULTS In the UK, in 2013,50% of patients commenced dialysis therapy with Hb 5100 g/L (median Hb 100 g/L). Of patients presenting early, 53% started dialysis with Hb 5100 g/L compared to 36% of patients presenting late. The UK median Hb of haemodialysis (HD) & peritoneal dialysis (PD) patients was 112 g/L (inter-quartile range (IQR) 103–120 g/L) and 113 g/L(IQR 103–122 g/L) respectively with 83% of patients having Hb .100 g/L for both treatment modalities. The median ferritin in HD and PD patients was 424 mg/L (IQR 280–616 mg/L) and 285 mg/L (IQR 167–473 mg/L) respectively with the majority of patients achieving ferritin 5100 mg/L.In EW&NI the median ESA dose was higher for HD than PD patients (7,333 vs. 4,000 IU/week). The percentage of patients treated with an ESA and having Hb .120 g/L ranged between centres from 3–29% for HD and from 0–26% for PD. CONCLUSIONS There continues to be significant variation between centres in the use of iron and ESAi n order to achieve the target Hb (100–120 g/L).