Mai Ots-Rosenberg

Renal replacement therapy in Europe: a summary of the 2013 ERA-EDTA Registry Annual Report with a focus on diabetes mellitus

Background This article provides a summary of the 2013 European Renal Association–European Dialysis and Transplant Association (ERA-EDTA) Registry Annual Report (available at http://www.era-edta-reg.org), with a focus on patients with diabetes mellitus (DM) as the cause of end-stage renal disease (ESRD). Methods In 2015, the ERA-EDTA Registry received data on renal replacement therapy (RRT) for ESRD from 49 national or regional renal registries in 34 countries in Europe and bordering the Mediterranean Sea. Individual patient data were provided by 31 registries, while 18 registries provided aggregated data. The total population covered by the participating registries comprised 650 million people. Results In total, 72 933 patients started RRT for ESRD within the countries and regions reporting to the ERA-EDTA Registry, resulting in an overall incidence of 112 per million population (pmp). The overall prevalence on 31 December 2013 was 738 pmp (n = 478 990). Patients with DM as the cause of ESRD comprised 24% of the incident RRT patients (26 pmp) and 17% of the prevalent RRT patients (122 pmp). When compared with the USA, the incidence of patients starting RRT pmp secondary to DM in Europe was five times lower and the incidence of RRT due to other causes of ESRD was two times lower. Overall, 19 426 kidney transplants were performed (30 pmp). The 5-year adjusted survival for all RRT patients was 60.9% [95% confidence interval (CI) 60.5–61.3] and 50.6% (95% CI 49.9–51.2) for patients with DM as the cause of ESRD.

The European Renal Association - European Dialysis and Transplant Association Registry Annual Report 2014: a summary.

Abstract Background This article summarizes the European Renal Association – European Dialysis and Transplant Association (ERA-EDTA) Registry’s 2015 Annual Report. It describes the epidemiology of renal replacement therapy (RRT) for end-stage renal disease (ESRD) in 2015 within 36 countries. Methods In 2016 and 2017, the ERA-EDTA Registry received data on patients who were undergoing RRT for ESRD in 2015, from 52 national or regional renal registries. Thirty-two registries provided individual patient-level data and 20 provided aggregated-level data. The incidence, prevalence and survival probabilities of these patients were determined. Results In 2015, 81 373 individuals commenced RRT for ESRD, equating to an overall unadjusted incidence rate of 119 per million population (pmp). The incidence ranged by 10-fold, from 24 pmp in Ukraine to 232 pmp in the Czech Republic. Of the patients commencing RRT, almost two-thirds were men, over half were aged ≥65 years and a quarter had diabetes mellitus as their primary renal diagnosis. Treatment modality at the start of RRT was haemodialysis for 85% of the patients, peritoneal dialysis for 11% and a kidney transplant for 4%. By Day 91 of commencing RRT, 82% of patients were receiving haemodialysis, 13% peritoneal dialysis and 5% had a kidney transplant. On 31 December 2015, 546 783 individuals were receiving RRT for ESRD, corresponding to an unadjusted prevalence of 801 pmp. This ranged throughout Europe by more than 10-fold, from 178 pmp in Ukraine to 1824 pmp in Portugal. In 2015, 21 056 kidney transplantations were performed, equating to an overall unadjusted transplant rate of 31 pmp. This varied from 2 pmp in Ukraine to 94 pmp in the Spanish region of Cantabria. For patients commencing RRT during 2006–10, the 5-year unadjusted patient survival probabilities on all RRT modalities combined was 50.0% (95% confidence interval 49.9–50.1).

Regular aquatic exercise for chronic kidney disease patients: a 10-year follow-up study.

Chronic kidney disease (CKD) patients not yet in dialysis can benefit from increased physical activity; however, the safety and outcomes of aquatic exercise have not been investigated in observational studies. The aim of this study was to analyze association of 10 years of regularly performed aquatic exercise with the study endpoint – that is, all-cause death or start of dialysis. Consecutive CKD patients were included in the study in January 2002. The exercise group (n=7) exercised regularly under the supervision of physiotherapist for 10 years; the control group (n=9), matched in terms of age and clinical parameters, remained sedentary. Low-intensity aerobic aquatic exercise was performed regularly twice a week; 32 weeks or more of exercise therapy sessions were conducted annually. None of the members of the aquatic exercise group reached dialysis or died in 10 years. In the sedentary control group, 55% reached the study endpoint – renal replacement therapy (n=2) or all-cause death (n=3). Occurrence of the study endpoint, compared using the exact multinomial test with unconditional margins, was statistically significantly different (P-value: 0.037) between the study groups. Regular supervised aquatic exercise arrested CKD progression. There was a statistically significant difference between the sedentary group and the exercise group in reaching renal replacement therapy or all-cause death in a follow-up time of 10 years.

Adverse lifestyle and health-related quality of life: gender differences in patients with and without chronic conditions

Objectives: The aim was to investigate the relationship between the main lifestyle-related factors and health-related quality of life (HRQoL) in a sample of patients with and without chronic conditions (CCs) with respect to the gender differences in both groups. Methods: A cross-sectional study was conducted on 1061 patients (of which 308 had no CCs and 753 of those had one or more CCs) recruited at primary health care centres and the Internal Medicine Clinic at Tartu University Hospital in Estonia. Data were collected during 2012–2014. The patient’s age, self-reported smoking status, alcohol consumption (assessed by Alcohol Use Disorders Identification Test) and body mass index were used as independent variables to predict the physical component scores (PCS) and mental component scores (MCS) of HRQoL (assessed by SF-36). Results: Smoking had a negative association with both physical and mental components of HRQoL only in women with CCs. Further, the PCS of chronically ill women was negatively associated with the higher body mass index. Harmful drinking had a negative association with the HRQoL in all patient groups, except with the PCS in women with CC. Light alcohol consumption without symptoms of harmful use or dependency had a positive association with the physical and mental HRQoL in all patient groups, except with the MCS in women without CCs. Conclusion: Adverse lifestyle had the most expressed association with HRQoL in women with CCs. Light alcohol consumption had a positive association, but harmful use of alcohol had an inverse association with HRQoL irrespective of patients’ gender or health status.

Peritoneal Dialysis Penetration and Peritonitis Rate at a Single Centre during Last Decade.

Peritoneal dialysis (PD) has been intensively offered at our centre to patients (pts) with end-stage renal disease (ESRD) from 2000, and the number of PD pts was noticed to raise. We aimed to analyse the PD population from the aspect of penetration and peritonitis rate during eleven years. Cumulative number of new RRT pts was 378 during the study period. We found high PD penetration rate: 53% (range 32–72%). The rate of peritonitis was as high as 9.8 during first study years, but it has declined progressively last year being 29.1 by September 2010 and 21.7 by December 2010. Most cases of peritonitis were due to gram-positive pathogens. We have demonstrated steady high single-centre PD penetration rate and improvement of management of patients during last decade probably because of the result of better pts education and a continued dedication of the staff.

Abdominal aortic calcifications predict survival in peritoneal dialysis patients

Background: Peripheral arterial disease and vascular calcifications contribute significantly to the outcome of dialysis patients. The aim of this study was to evaluate the prognostic role of severity of abdominal aortic calcifications and peripheral arterial disease on outcome of peritoneal dialysis (PD) patients using methods easily available in everyday clinical practice. Methods: We enrolled 249 PD patients (mean age 61 years, 67% male) in this prospective, observational, multicenter study from 2009 to 2013. The abdominal aortic calcification score (AACS) was assessed using lateral lumbar X ray, and the ankle-brachial index (ABI) using a Doppler device. Results: The median AACS was 11 (range 0 – 24). In 58% of the patients, all 4 segments of the abdominal aorta showed deposits, while 19% of patients had no visible deposits (AACS 0). Ankle-brachial index was normal in 49%, low (< 0.9) in 17%, and high (> 1.3) in 34% of patients. Altogether 91 patients (37%) died during the median follow-up of 46 months. Only 2 patients (5%) with AACS 0 died compared with 50% of the patients with AACS ≥ 7 (p < 0.001). The adjusted hazard ratio for all-cause mortality was 4.85 (95% confidence interval [CI] 1.94 – 24.46) for aortic calcification (AACS ≥ 7), 2.14 for diabetes (yes/no), 0.93 for albumin (per 1 g/L), and 1.04 for age (per year). A low or high ABI were not independently associated with mortality. Conclusions: Severe aortic calcification was a strong predictor of all-cause mortality in PD patients. The evaluation of aortic calcifications by lateral X ray is a simple method that allows the identification of high-risk patients.

Improvements in renal replacement therapy practice patterns in estonia.

Background: The clinical performance indicators (CPI) are important tools to assess and improve the quality of renal replacement therapy (RRT). The aim of the current study was to compare the results of a longitudinal set of CPI in RRT patients and to determine the extent to which the guidelines for anaemia, calcium phosphate management and other CPI are met in Estonian renal centres. Methods: A long-term retrospective, observational, cross-sectional CPI analysis was undertaken in RRT patients from 2007 to 2011. The following CPI set of well-designed measures based on good evidence was analysed: anaemia management variables, laboratory analyses of mineral metabolism, nutritional status variables and dialysis adequacy variables. Results: Relatively small changes in the analysed mean CPI values were noticed during the study period. In the course of the study, we noticed an improvement in anaemia control, but not all centres achieved the standard of >80% of the dialysis patients with a haemoglobin (Hb) level >100 g/l. There was a trend of decreasing Hb concentrations below 125 g/l in both haemodialysis (HD) and peritoneal dialysis (PD) patients. In 2011, hyperphosphataemia was present in 58% of the HD and 47% of the PD patients, whereas centre differences varied between 50 and 60% of both the HD and PD patients. HD adequacy was achieved in 77% of the HD patients. Conclusion: An improvement in the data collection was noticed, and the analysis of CPI allows renal centres to assess and compare their practices with others. The collection and evaluation of CPI of RRT patients is an important improvement and significantly increases the awareness of nephrologists.

Sudden Cardiac Arrest in Chronic Kidney Disease

Chronic kidney disease (CKD) is a worldwide health problem with increasing incidence, prevalence, morbidity, and mortality. Death from cardiovascular disease in general and sudden cardiac arrest (SCA) in particular are exponentially proportional to declining renal function and are a major cause of mortality among all those with CKD. The greatest risk however is reserved for patients with end-stage renal disease (ESRD) on chronic dialysis. These individuals have an extraordinarily high mortality with an annual death rate of 221 deaths per 1,000 patient-years. Cardiac disease is the major cause of death in these patients, accounting for 45 % of all-cause mortality regardless of the mode of dialysis. Of these, 60 % appear to be due to SCA, making this single diagnosis responsible for a quarter of all-cause mortality. Once cardiac arrest occurs in this group of patients, survival is poor. Even if the arrest occurred in the controlled setting of a dialysis unit, the majority will have died within 48 h and the 6-month survival rate among those dialysis patients successfully resuscitated is dismal. Thus, reducing mortality from cardiovascular disease among ESRD patients, including those due to SCA from arrhythmic events, is a global health challenge. The main objectives of this chapter are to elucidate the nature of SCA in the kidney diseases population, describe possible mechanisms and risk factors, and discuss options for prevention.