Julie Gilg

UK Renal Registry 17th Annual Report: Chapter 1 UK Renal Replacement Therapy Incidence in 2013: National and Centre-specific Analyses

INTRODUCTION This chapter describes the characteristics of adult patients starting renal replacement therapy (RRT) in the UK in 2013 and the incidence rates for RRT by Clinical Commissioning Groups and Health Boards (CCG/HBs) in the UK. METHODS Basic demographic and clinical characteristics,including presentation time (time between first being seen by a nephrologist and start of RRT), and age/gender standardised incidence ratios in CCG/HBs, are reported on patients starting RRT at all UK renal centres. RESULTS In 2013, RRT was started in 7,006 patients across the UK,with an incidence rate similar to 2012 at 109 per million population (pmp). There were wide variations between CCG/HBs in standardised incidence ratios. The median age for White patients was 66.0 and for non-White patients 57.0 years. Diabetic renal disease remained the single most common cause of renal failure (25%). By 90 days,66.1% of patients were on haemodialysis (HD), 19.0% on peritoneal dialysis (PD), 9.5% had a functioning transplant and 5.3% had died or stopped treatment. There continued to be variability between centres in the use of PD as an initial treatment. The mean eGFR at the start of RRT was 8.5 ml/min/1.73 m2 similar to previous years. Late presentation(,90 days) fell from 23.9% in 2006 to 18.4% in 2013. Fifty-one percent of patients who started on HD had died within five years of starting. This compared to 33% and 5% for those starting on PD or transplant respectively. CONCLUSIONS The incidence of new patients starting RRT in the UK has remained largely unchanged for almost 10 years in contrast to the rising numbers of prevalent patients (+48% since 2003). The year on year increase in pre-emptive transplantation is encouraging but the variability between centres in the percentages starting on PD should be explored further.

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.

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%).

Chapter 1: UK RRT Incidence in 2009: National and Centre-Specific Analyses

Introduction: This chapter describes the characteristics of adult patients starting renal replacement therapy (RRT) in the UK in 2010 and the incidence rates for RRT in Primary Care Trusts and Health Boards (PCT/HBs) in the UK. Methods: The basic demographics and clinical characteristics are reported on patients starting RRT from 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 2010, the incidence rates in the UK and England were similar to 2009 at 107 per million population (pmp). The incidence rate fell in Scotland (from 104 pmp to 95 pmp), increased in Northern Ireland (from 88 pmp to 101 pmp) and Wales (from 120 pmp to 128 pmp). There were wide variations between PCT/HBs in standardised incidence ratios. The median age of all incident patients was 64.9 years (IQR 51.0, 75.2). For transplant centres this was 63.1 years (IQR 49.7, 74.2) and for non-transplanting centres 66.5 years (IQR 52.9, 76.0). The median age for non-Whites was 57.1 years. Diabetic renal disease remained the single most common cause of renal failure (24%). By 90 days, 68.3% of patients were on haemodialysis, 18.1% on peritoneal dialysis, 7.7% had had a transplant and 5.9% had died or stopped treatment. The mean eGFR at the start of RRT was 8.7 ml/ min/1.73 m2 which was similar to the previous three years. Late presentation (<90 days) fell from 28.2% in 2005 to 20.6% in 2010. There was no relationship between social deprivation and presentation pattern. Conclusions: Incidence rates have plateaued in England over the last five years. They have fallen in Scotland and fallen and then risen again in Northern Ireland and Wales. Wales continued to have the highest incidence rate of the countries making up the UK.

UK Renal Registry 11th Annual Report (December 2008): Chapter 6 Comorbidities and current smoking status amongst patients starting Renal Replacement Therapy in England, Wales and Northern Ireland: national and centre-specific analyses

Introduction: The prevalence of 13 comorbid conditions and smoking status at the time of starting renal replacement therapy (RRT) in England, Wales and Northern Ireland are described. Methods: Adult patients starting RRT between 2002 and 2007 in centres reporting to the UK Renal Registry (UKRR) and with data on comorbidity (n = 13,293) were included. The association of comorbidity with patient demographics, treatment modality, haemoglobin, renal function at start of RRT and subsequent listing for kidney transplantation were studied. Association between comorbidities and mortality at 90 days and one year after 90 days from start of RRT was explored using Cox regression. Results: Completeness of data on comorbidity returned to the UKRR remained poor. Of patients with data, 52% had one or more comorbidities. Diabetes mellitus and ischaemic heart disease were the most common conditions seen in 28.9% and 22.5% of patients respectively. Comorbidities became more common with increasing age (up to the 65–74 age group), were more common amongst Whites and were associated with a lower likelihood of pre-emptive transplantation, a greater likelihood of starting on haemodialysis (rather than peritoneal dialysis) and a lower likelihood of being listed for kidney transplantation. In multivariable survival analysis, malignancy and ischaemic/neuropathic ulcers were the strongest predictors of poor survival at 1 year after 90 days from start of RRT. Conclusions: The majority of patients had at least one comorbid condition and comorbidity is an important predictor of early mortality on RRT.

UK Renal Registry 13th Annual Report (December 2010): Chapter 15: UK renal centre survey results 2010: RRT incidence and use of home dialysis modalities.

Introduction: RRT incidence rates and the proportion of patients using a home dialysis modality (peritoneal or home haemodialysis) varies widely between centres and persists even after area differences in age, ethnicity and social deprivation structure are taken into account. A nationwide survey was undertaken to identify possible drivers of this variation. Methods: A systematic literature review followed by a two-stage Delphi consensus technique was employed to identify renal centre characteristics and practice patterns that may be important in determining either RRT incidence or home modality usage. Results: All 72 (100%) of UK adult renal centres responded. Questions about staffing numbers, interface with primary care, interface with other secondary care sites, capacity within the HD programme, constituents of pre-dialysis education programmes, conservative management programmes, range of treatments available, dialysis access and training and physician attitudes to home modalities were included. Conclusions: There was wide variation in practice patterns and centre characteristics across the UK. Overall, physician enthusiasm for home dialysis modalities was greater than the actual usage of home dialysis.

UK Renal Registry 13th Annual Report (December 2010): Chapter 1: UK RRT incidence in 2009: national and centre-specific analyses.

Introduction: This chapter describes the characteristics of adult patients starting renal replacement therapy (RRT) in the UK in 2009 and the acceptance rates for RRT in Primary Care Trusts and Health Boards (PCT/HBs) in the UK. Methods: The basic demographics and clinical characteristics are reported on patients starting RRT from all UK renal centres. Late presentation, 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 rates in PCT/HBs were calculated. Results: In 2009, the incidence rate in the UK and England was 109 per million population (pmp). Acceptance rates in Scotland (104 pmp), Northern Ireland (88 pmp) and Wales (120 pmp) had all fallen although Wales still remained the country with the highest acceptance rate. There were wide variations between PCT/HBs with respect to the standardised ratios. The median age of all incident patients was 64.8 years (IQR 50.8, 75.1). For transplant centres this was 63.0 years (IQR 49.0, 74.2) and for non-transplanting centres 66.3 years (IQR 52.6, 75.9). The median age for non-Whites was 57.1 years. Diabetic renal disease remained the single most common cause of renal failure (25%). By 90 days, 69.1% of patients were on haemodialysis, 17.7% on peritoneal dialysis, 6.7% had had a transplant and 6.5% had died or stopped treatment. The mean eGFR at the start of RRT was 8.6 ml/min/1.73 m2 which was similar to the previous two years. Late presentation (<90 days) has fallen from 27% in 2004 to 19% in 2009. There was no relationship between social deprivation and presentation pattern. Conclusions: Acceptance rates have fallen in Northern Ireland, Scotland and Wales whilst they have plateaued in England over the last four years. Wales continued to have the highest acceptance rate of the countries making up the UK.

UK Renal Registry 13th Annual Report (December 2010): Chapter 4: comorbidities and current smoking status amongst patients starting renal replacement therapy in England, Wales and Northern Ireland from 2008 to 2009.

Introduction: Comorbidity is an important determinant of survival for renal replacement therapy patients and impacts other care processes such as dialysis access creation and transplant wait-listing. The prevalence of comorbidities in incident patients on renal replacement therapy (RRT) changes with age and varies between ethnic groups. This study describes these associations and the independent effect of comorbidities on outcomes. Methods: Incident patients reported to the UK Renal Registry (UKRR) with comorbidity data in 2008 and 2009 (n = 5,617) were included in analyses exploring the association of comorbidity with patient demographics, treatment modality, haemoglobin and renal function at start of RRT. For analyses examining comorbidity and survival, adult patients starting RRT between 2004 and 2009 in centres reporting to the UKRR with comorbidity data (n = 16,527) were included. The relationship between comorbidities and mortality at 90 days and one year after 90 days from start of RRT was explored using Cox regression. Results: Completeness of comorbidity data was 44.4% in 2009 compared with 52.1% in 2004. Of patients with data, 56.5% had one or more comorbidities. Diabetes mellitus and ischaemic heart disease were the most common conditions seen in 32.9% and 22.5% of patients respectively. Current smoking was recorded for 12.4% of incident RRT patients in the 2-year period. The presence of comorbidities in patients <75 years became more common with increasing age in all ethnic groups. In multivariable survival analysis, malignancy and the presence of ischaemic/neuropathic ulcers were the strongest independent predictors of poor survival at 1 year after 90 days from the start of RRT in patients <65 years. Conclusion: Differences in prevalence rates of comorbid illnesses in incident RRT patients may reflect variation in access to health care or competing risk prior to commencing treatment. The interpretation of analyses continues to be limited by poor data completeness.

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.

How much of the regional variation in RRT incidence rates within the UK is explained by the health needs of the general population

BACKGROUND Variation in end-stage renal disease treatment rates in the UK persist after adjustment for socio-demographic factors. METHODS UK-wide ecological study using population socio-demographic factors, health status characteristics and access to health services factor in to explain the incidence of renal replacement therapy (RRT). RESULTS There was a 6% higher incidence rate of RRT per standard deviation (SD) increase in area diabetes prevalence after adjustment for area level socio-economic deprivation status and the proportion of non-white residents [incidence rate ratio adjusted (IRR adjusted) 1.06 (95% confidence interval 1.03,1.09), P < 0.001]. A 3% lower-adjusted RRT incidence rate was seen with each SD higher proportion of diabetics achieving an HbA1c of <7.5% [IRR 0.97 (0.94, 1.00), P = 0.03]. Hypertension prevalence was independently associated with an 8% higher RRT incidence rate per SD increase [IRR adjusted 1.08 (1.04, 1.11), P < 0.001] and an SD increase in life expectancy in an area was independently associated with 7% lower RRT incidence rate [IRR adjusted 0.93 (0.91, 0.96), P < 0.001]. An SD increase in premature cardiovascular (CV) mortality rate in an area was also independently associated with RRT incidence rates [IRR adjusted 1.06 (1.03, 1.09), P < 0.001]. Rates of coronary artery bypass grafting (CABG)/angioplasty and knee replacement were positively associated with RRT incidence, but mammography uptake was not associated. In total, 31% of the regional variation in RRT incidence could be explained by these factors. CONCLUSIONS Diabetes prevalence, the proportion of diabetics achieving good glycaemic control, hypertension prevalence, life expectancy, premature CV mortality, CABG/angioplasty and knee replacement rates were all associated with RRT incidence. A third of the regional variation in RRT incidence between areas can be explained by these demographic, health and access to health services factors.