Catherine Byrne

Survival of patients from South Asian and Black populations starting renal replacement therapy in England and Wales

Background. South Asian and Black ethnic minorities in the UK have higher rates of acceptance onto renal replacement therapy (RRT) than Caucasians. Registry studies in the USA and Canada show better survival; there are few data in the UK. Methods. Renal Association UK Renal Registry data were used to compare the characteristics and survival of patients starting RRT from both groups with those of Caucasians, using incident cases accepted between 1997 and 2006. Survival was analysed by multivariate Coxs proportional hazards regression split by haemodialysis and peritoneal dialysis (PD) due to non-proportionality, and without censoring at transplantation. Results. A total of 2495 (8.2%) were South Asian and 1218 (4.0%) were Black. They were younger and had more diabetic nephropathy. The age-adjusted prevalence of vascular co-morbidity was higher in South Asians and lower in Blacks; other co-morbidities were generally common in Caucasians. Late referral did not differ. They were less likely to receive a transplant or to start PD. South Asians and Blacks had significantly better survival than Caucasians both from RRT start to Day 90 and after Day 90, and for those on HD or PD at Day 90. Fully adjusted hazard ratios after Day 90 on haemodialysis were 0.70 (0.55–0.89) for South Asians and 0.56 (0.41–0.75) for Blacks. Conclusion. South Asian and Black minorities have better survival on dialysis. An understanding of the mechanisms may provide general insights for all patients on RRT.

UK Renal Registry 12th Annual Report (December 2009): chapter 3: UK ESRD incident rates in 2008: national and centre-specific analyses.

Introduction: This chapter describes the characteristics of adult patients starting renal replacement therapy (RRT) in the UK in 2008 and the acceptance rates for RRT in Primary Care Trusts and Local Authorities (PCT/LAs) in the UK. Methods: The basic demographics and clinical characteristics are reported on patients starting RRT from all UK renal centres. Late referral, defined as time between first being seen by a nephrologist and start of RRT being <90 days was also studied. Age and gender standardised ratios for acceptance rate in PCT/LAs were calculated. Results: In 2008, the acceptance rate in the UK was 108 per million population (pmp). Acceptance rates in Scotland (103 pmp), Northern Ireland (97 pmp) and Wales (117 pmp) have all fallen although Wales still remains the country with the highest acceptance rate. There were wide variations between PCT/LAs with respect to the standardised ratios, which were lower in more PCT/LAs in the North West and South East of England and higher in London, the West Midlands, Scotland, Northern Ireland, and Wales. The median age of all incident patients was 64.1 years and for non-Whites 56.1 years. Diabetic renal disease remains the single most common cause of renal failure (24%). By 90 days, 67.7% of patients were on haemodialysis, 19.8% on peritoneal dialysis, 5.9% had had a transplant and 6.6% had died or had stopped treatment. By 90 days, 77.4% of all dialysis patients were on HD. The geometric mean eGFR at the start of RRT was 8.6 ml/min/ 1.73 m2 which was similar to the eGFR of those starting in 2007. The incidence of late presentation (<90 days) has fallen from 28% in 2003 to 22% in 2008. There was no relationship between social deprivation and referral pattern. Conclusions: Acceptance rates have fallen in Northern Ireland, Scotland and Wales whilst they have plateaued in England over the last three years. Wales continued to have the highest acceptance rate of the countries making up the UK.

Chapter 4: UK ESRD Prevalent Rates in 2008: national and centre-specific analyses

Introduction: This chapter describes the characteristics of adult patients starting renal replacement therapy (RRT) in the UK in 2008 and the acceptance rates for RRT in Primary Care Trusts and Local Authorities (PCT/LAs) in the UK. Methods: The basic demographics and clinical characteristics are reported on patients starting RRT from all UK renal centres. Late referral, defined as time between first being seen by a nephrologist and start of RRT being <90 days was also studied. Age and gender standardised ratios for acceptance rate in PCT/LAs were calculated. Results: In 2008, the acceptance rate in the UK was 108 per million population (pmp). Acceptance rates in Scotland (103 pmp), Northern Ireland (97 pmp) and Wales (117 pmp) have all fallen although Wales still remains the country with the highest acceptance rate. There were wide variations between PCT/LAs with respect to the standardised ratios, which were lower in more PCT/LAs in the North West and South East of England and higher in London, the West Midlands, Scotland, Northern Ireland, and Wales. The median age of all incident patients was 64.1 years and for non-Whites 56.1 years. Diabetic renal disease remains the single most common cause of renal failure (24%). By 90 days, 67.7% of patients were on haemodialysis, 19.8% on peritoneal dialysis, 5.9% had had a transplant and 6.6% had died or had stopped treatment. By 90 days, 77.4% of all dialysis patients were on HD. The geometric mean eGFR at the start of RRT was 8.6 ml/min/ 1.73 m2 which was similar to the eGFR of those starting in 2007. The incidence of late presentation (<90 days) has fallen from 28% in 2003 to 22% in 2008. There was no relationship between social deprivation and referral pattern. Conclusions: Acceptance rates have fallen in Northern Ireland, Scotland and Wales whilst they have plateaued in England over the last three years. Wales continued to have the highest acceptance rate of the countries making up the UK.

Renal Arcuate Vein Microthrombi-Associated AKI

BACKGROUNDS AND OBJECTIVES This report describes six patients with AKI stages 2-3 (median admission creatinine level, 2.75 mg/dl [range, 1.58-5.44 mg/dl]), hematuria (five with hemoproteinuria), and unremarkable imaging with an unusual and unexplained histologic diagnosis on renal biopsy. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The patients were young adults who presented to two neighboring United Kingdom nephrology centers over a 40-month period (between July 2010 and November 2013). Four were male, and the median age was 22.5 years (range, 18-27 years). Their principal symptoms were flank pain or lower back pain. All had consumed alcohol in the days leading up to admission. RESULTS Renal biopsy demonstrated microthrombi in the renal arcuate veins with a corresponding stereotypical, localized inflammatory infiltrate at the corticomedullary junction. All patients recovered to baseline renal function with supportive care (median, 17 days; range, 6-60 days), and none required RRT. To date, additional investigations have not revealed an underlying cause for these histopathologic changes. Investigations have included screening for thrombophilic tendencies, renal vein Doppler ultrasonographic studies, and testing for recreational drugs and alcohol (including liquid chromatography-mass spectrometry of urine) to look for so-called designer drugs. Inquiries to the United Kingdom National Poisons Information Centre have identified no other cases with similar presentation or histologic findings. CONCLUSIONS Increased awareness and additional study of future cases may lead to a greater understanding of the underlying pathophysiologic mechanisms that caused AKI in these patients.

Appendix D: Methodology used for Analyses of PCT/ Local Authority Incidence and Prevalence Rates and of Standardised Ratios

The areas used were the 148 English primary care trusts (PCTs), the 4 English care trusts, the 22 Welsh local authorities, the 32 Scottish council areas and the 26 Northern Ireland district council areas – these different types of area are collectively called PCT/LAs here. In Northern Ireland, Scotland and Wales, the health authority boundaries align with the LAs and these areas have been included along with the English PCTs in the tables.

UK Renal Registry 19th Annual Report: Appendix I Acronyms and Abbreviations used in the Annual Report

AAB Academic Affairs Board (Renal Association) ACE (inhibitor) Angiotensin converting enzyme (inhibitor) AKI Acute kidney injury ANZDATA Australia and New Zealand Dialysis and Transplant Registry APD Automated peritoneal dialysis ADPKD Autosomal dominant polycystic kidney disease APKD Adult polycystic kidney disease ATTOM Access to transplant and transplant outcome measures ATTOMic Access to transplant and transplant outcome measures in children AV Arteriovenous AVF Arteriovenous fistula AVG Arteriovenous graft BAPN British Association of Paediatric Nephrology BCG Bromocresol green BCP Bromocresol purple Bicarb Bicarbonate BMD Bone mineral disease BMI Body mass index BP Blood pressure BSI Blood stream infection BTS British Transplant Society Ca Calcium CAB Clinical Affairs Board (Renal Association) CABG Coronary artery bypass grafting CAPD Continuous ambulatory peritoneal dialysis CCG Clinical Commissioning Group CCL Clinical Computing Limited CCPD Cycling peritoneal dialysis CDI Clostridium difficile infection Chol Cholesterol CHr Target reticulocyte Hb content CI Confidence interval CICR Cumulative incidence competing risk CIF Cumulative incidence function CK Creatine kinase CKD Chronic kidney disease CKD-EPI Chronic kidney disease epidemiology collaboration CK-MB Creatine kinase isoenzyme MB CKD-MBD Chronic kidney diseasemineral bone disorder COPD Chronic obstructive pulmonary disease

UK Renal Registry 12th Annual Report (December 2009): chapter 4: UK ESRD prevalent rates in 2008: national and centre-specific analyses.

Introduction: This chapter describes the characteristics of adult patients starting renal replacement therapy (RRT) in the UK in 2008 and the acceptance rates for RRT in Primary Care Trusts and Local Authorities (PCT/LAs) in the UK. Methods: The basic demographics and clinical characteristics are reported on patients starting RRT from all UK renal centres. Late referral, defined as time between first being seen by a nephrologist and start of RRT being <90 days was also studied. Age and gender standardised ratios for acceptance rate in PCT/LAs were calculated. Results: In 2008, the acceptance rate in the UK was 108 per million population (pmp). Acceptance rates in Scotland (103 pmp), Northern Ireland (97 pmp) and Wales (117 pmp) have all fallen although Wales still remains the country with the highest acceptance rate. There were wide variations between PCT/LAs with respect to the standardised ratios, which were lower in more PCT/LAs in the North West and South East of England and higher in London, the West Midlands, Scotland, Northern Ireland, and Wales. The median age of all incident patients was 64.1 years and for non-Whites 56.1 years. Diabetic renal disease remains the single most common cause of renal failure (24%). By 90 days, 67.7% of patients were on haemodialysis, 19.8% on peritoneal dialysis, 5.9% had had a transplant and 6.6% had died or had stopped treatment. By 90 days, 77.4% of all dialysis patients were on HD. The geometric mean eGFR at the start of RRT was 8.6 ml/min/ 1.73 m2 which was similar to the eGFR of those starting in 2007. The incidence of late presentation (<90 days) has fallen from 28% in 2003 to 22% in 2008. There was no relationship between social deprivation and referral pattern. Conclusions: Acceptance rates have fallen in Northern Ireland, Scotland and Wales whilst they have plateaued in England over the last three years. Wales continued to have the highest acceptance rate of the countries making up the UK.

Appendix E: Additional Data Tables for 2008 new and existing patients

Abrdn 85 15 L Rfree 84 11 4 Airdrie 92 8 L St.G 62 18 20 Antrim 90 10 LWest 86 4 9 B Heart 84 14 2 Leeds 69 20 11 B QEH 73 23 4 Leic 79 10 12 Bangor 86 14 Liv Ain 98 2 Basldn 83 18 Liv RI 66 27 7 Belfast 84 12 4 M Hope 46 46 7 Bradfd 85 15 M RI 71 16 13 Brightn 66 33 1 Middlbr 80 13 8 Bristol 75 19 6 Newc 72 22 6 Camb 87 10 3 Newry 85 15 Cardff 78 15 7 Norwch 79 15 5 Carlis 74 23 3 Nottm 73 22 5 Carsh 85 14 1 Oxford 62 27 12 Chelms 73 27 Plymth 56 26 19 Clwyd 92 8 Ports 68 24 8 Colchr 100 Prestn 74 20 6 Covnt 74 19 6 Redng 70 25 5 Table E.1.2. Number of patients per treatment modality at 90 days