Rudolf Trapp

Costs of dialysis—a regional population-based analysis

BACKGROUND Population-based estimates of costs of renal replacement therapy are scarce in the literature. The aim of our study was to calculate the costs of long-term dialysis in 2006 on the basis of patient-specific data from a well-defined population in a region in western Germany (n = 310,757). METHODS Cost estimation was performed from the perspective of the statutory health insurance. All dialysis patients from the study region (n = 344, 54% male, mean age (+/-SD) 69 +/- 13 years, 42% diabetic) were assessed for the costs of the dialysis procedures, dialysis-related hospital admissions, outpatient contacts outside of our dialysis center, dialysis-related medication, patient transportation and related costs (e.g. reimbursement fees on the basis of the German diagnosis-related group system, price scales). We estimated the cumulative cost per patient year in 2006 (in Euros), along with the 10th and 90th percentiles and the 95% confidence intervals (CI) by using bootstrapping procedures. RESULTS The mean total dialysis-related cost in 2006 was 54,777 Euros (95% CI, 51,445-65,705) per patient year. The largest part of the costs (55%) was caused by the dialysis procedures, followed by the costs of medication (22%), hospitalization (14%) and transportation (8%). The total cost increased significantly with increasing age. No significant association was found between total cost and sex, dialysis strategy, end-stage renal disease duration and diabetes. CONCLUSIONS We present for the first time a cost estimation of dialysis in Germany on the basis of patient-level data in a population-based sample. Except age, patient characteristics were not significantly associated with costs. The largest part of the costs was caused by the dialysis procedures themselves; however, other dialysis-specific health care utilization also strongly contributed to the total cost.

Comparable outcome of acute unplanned peritoneal dialysis and haemodialysis

BACKGROUND The impact of dialysis modality on outcome, especially on infection early in the course of dialysis, in unplanned acute dialysis initiation has not been well evaluated. The aim of the study was to compare the rates and causes of mortality and morbidity in incident dialysis patients started unplanned acute peritoneal dialysis (PD) or haemodialysis (HD). PATIENTS AND METHODS In this observational cohort study, incident dialysis patients with initiation of unplanned and acute PD (n = 66) or HD (n = 57) at a single centre from March 2005 to June 2010 were included and followed up for 6 months (0-183 days, mean follow-up time 4.72 months). For PD, surgically placed Tenckhoff catheters were used. All HD patients were dialysed with a central venous catheter (non-tunnelled or tunnelled). There were no significant differences in terms of gender, age and prevalence of diabetes mellitus in either group. The prevalence of heart failure [New York Heart Association (NYHA) Stage III-IV] was significantly higher in the PD group (73 versus 46% in HD group, P < 0.01). The population was stratified to PD and HD comparing mortality, infection, bacteraemia and hospitalization. RESULTS Of the 123 patients who commenced acute and unplanned dialysis, n = 44 (35.8%) died during the follow-up period of 0-183 days. There were no significant difference in half-year mortality in n = 20 PD patients (30.3%) versus n = 24 HD patients (42.1%) (P = 0.19). The cardiovascular mortality in PD and HD patients were 9.1 and 10.5%, respectively (P = 1.00). Overall mortality due to infection was higher in the HD (17.5%) versus in the PD group (9.1%), however, not significant (P = 0.19). HD patients had significantly higher probability of bacteraemia in the first 183 days compared to PD patients (21.1 versus 3.0%, P < 0.01). Group comparison by Poisson regression analyses showed that the relative risk of bacteraemia in the PD group versus HD group was 0.16 (95% confidence interval, 0.05-0.57, P = 0.005). The significant difference was not affected by the confounders patient age at time of dialysis, male sex, heart failure (NYHA III-IV), diabetes, malignancy and peripheral arterial occlusive disease Stage IV. There were high proportions of hospitalization after the initiation of dialysis in both groups (PD 75.0% and HD 67.3%, P = 0.40). Univariate and multiple regression analyses revealed only age at initiation of dialysis to be significantly associated with overall mortality (P < 0.05). CONCLUSIONS Dialysis modality (PD versus HD) in an acute unplanned dialysis setting showed, in our population, no significant influence on survival. HD patients had a significantly higher risk of bacteraemia, perhaps due to central venous dialysis catheter. PD seems to be a safe and efficient, at least comparable, alternative to HD in acute unplanned dialysis settings.

Peritoneal dialysis relieves clinical symptoms and is well tolerated in patients with refractory heart failure and chronic kidney disease

The aim of the study was to evaluate the efficacy and clinical outcome of peritoneal dialysis (PD) treatment in patients with severe refractory heart failure (HF) and chronic kidney disease (CKD).

Incidence of renal replacement therapy (RRT) in the diabetic compared with the non-diabetic population in a German region, 2002-08.

BACKGROUND This study was conducted to estimate incidences of renal replacement therapy (RRT) in the diabetic and non-diabetic populations in Germany, as well as relative and attributable risks of RRT due to diabetes. METHODS Using the data of a regional dialysis centre (region population of 310 000), we assessed all incident RRT patients aged 30 years or older in 2002-08. We estimated sex- and age-specific and -standardized incidences of RRT in the diabetic and non-diabetic populations, which were estimated by applying diabetes prevalences from a population-based study, and relative and attributable risks due to diabetes. RESULTS Of all subjects with incident RRT (n = 544), 49.6% had diabetes. Fifty-eight percent were male, mean age (SD) was 70.3 years (11.4 years). Incidences per 100 000 person-years (standardized to the 2004 German population) in the diabetic and the non-diabetic populations were 213.7 [95% confidence interval (95% CI), 159.5-267.8] and 26.9 (95% CI, 22.5-31.3) in men and 130.2 (95% CI, 65.6-194.9) and 16.4 (95% CI, 13.5-19.3) in women, respectively. Standardized relative risks were 7.9 (5.9-10.8) in men and 8.0 (4.7-13.5) in women. There was a significant interaction between age and diabetes, with lower relative risks in higher ages. Attributable risks among diabetic individuals were 0.87 in men and women, and population-attributable risks were 0.41 and 0.35 in men and women, respectively. CONCLUSIONS In this population-based study in a German region, we found the relative risk of RRT in the estimated adult diabetic population to be 8-fold increased compared with the non-diabetic population. A high proportion of the RRT risk can be attributed to diabetes in the diabetic as well as in the whole population.

Value of Diabetes as an Independent Predictor of Death in Subjects with End-Stage Renal Disease

Background and Purpose:Diabetic subjects on hemodialysis have a poor survival. The authors performed a Kaplan-Meier survival analysis of diabetic versus nondiabetic subjects and investigated the value of diabetes as an independent predictor of death in these end-stage renal disease (ESRD) subjects.Patients and Methods:From 1997 to 2003, 135 ESRD subjects (41 diabetics) were enrolled in a survival study beginning at the start of dialysis. Inclusion criterion was onset of dialysis at least 6 months before study entry. Exclusion criteria comprised age < 45 years, coronary artery disease (CAD), critical limb ischemia (CLI), or malignancies at ESRD onset up to 6 months after study entry. Subjects with clinical signs of vascular disease were followed up by coronary or peripheral angiographies.Results:Baseline risk factors were similar between diabetic and nondiabetic subjects. The 5-year survival rate in nondiabetic subjects was 76.9% (95% confidence interval [CI] = 62–86%) versus 76.4% (95% CI = 53–89%) in diabetic patients (p = 0.402). Consistent with this finding, the Cox proportional hazards model revealed that diabetes does not significantly change the risk of death in ESRD subjects. De novo CAD developed in 35 and CLI in ten subjects, but both diseases were present more frequently in nonsurvivors (42% vs. 23%; p = 0.052) versus survivors (21% vs. 5%; p = 0.005).Conclusion:Diabetes is not an independent predictor of death in the ESRD study group presented here. Prevention of CAD and CLI in diabetic subjects is most important to improve survival.ZusammenfassungHintergrund und Ziel:Die Autoren führten eine Kaplan-Meier-Analyse bei diabetischen und nichtdiabetischen Dialysepatienten durch und untersuchten die Bedeutung des Diabetes als unabhängigen Prädiktor für den Tod.Patienten und Methodik:Von 1997 bis 2003 wurden 135 Patienten mit terminaler Niereninsuffizienz (41 Diabetiker) in die Überlebensstudie aufgenommen. Studienbeginn war der Start der Dialyse. Einschlusskriterium war Dialysebeginn mindestens 6 Monate vor Studieneintritt. Ausschlusskriterien umfassten Alter < 45 Jahre, koronare Herzkrankheit (KHK), kritische Beinischämie (KBI) oder Malignom zu Dialysebeginn und bis zu 6 Monate nach Studieneintritt. Patienten mit klinischen Anzeichen einer Gefäßkrankheit wurden mittels koronarer oder peripherer Angiographie untersucht.Ergebnisse:Die Risikofaktoren vor Studienbeginn waren bei Diabetikern und Nichtdiabetikern ähnlich. Die 5-Jahres-Überlebensrate betrug bei Nichtdiabetikern 76,9% (95%-Konfidenzintervall [CI] = 62–86%) versus 76,4% (95%-CI = 53–89%) bei Diabetikern (p = 0,402). Das Cox-Modell zeigte, dass Diabetes das Todesrisiko statistisch nicht signifikant verändert. Eine De-novo-KHK trat bei 35 und eine KBI bei zehn Patienten auf, aber beide Krankheiten waren bei den verstorbenen Patienten (42% vs. 23%; p = 0,052) häufiger zu finden als bei den überlebenden Patienten (21% vs. 5%; p = 0,005).Schlussfolgerung:Diabetes ist kein unabhängiger Prädiktor für den Tod in der hier vorgestellten Studiengruppe. Die Prävention von KHK und KBI bei Diabetikern hat für eine Verbesserung des Überlebens eine große Bedeutung.

Time-dependent impact of diabetes on the mortality of patients on renal replacement therapy: a population-based study in Germany (2002-2009).

AIMS To estimate the impact of diabetes on the mortality of patients with incident renal replacement therapy (RRT). METHODS We assessed the mortality of 544 incident RRT patients aged ≥ 30 years between 2002 and 2009 (57.9% men, mean age 70.3 years, 49.6% patients with diabetes) by analyzing the data of all dialysis centers covering a German region. We compared the estimated time-dependent hazard ratios of patients with and without diabetes by using the Cox proportional-hazards regression model. RESULTS Overall, 319 patients had died (158 diabetic), approximately 50% after 3 years. Up to about 3 years, the mortality rate was lower in diabetic than in nondiabetic patients. Thereafter, the survival curves crossed (interaction diabetes × time, p = 0.002; adjusted hazard ratios for diabetes: baseline, 0.66; year 1, 0.84; year 2, 1.05; year 3, 1.33; year 4, 1.68). The results were similar in men and women; however, the interaction of diabetes and time was significant only in men (p = 0.004). Further significant risk factors of mortality were age, sex, initial central venous catheter, cardiovascular disease, and malignancy. CONCLUSIONS In this population-based study, the influence of diabetes was time-dependent, with a lower mortality in diabetic versus non-diabetic patients in the first three years but a higher mortality in these patients after 3 years. Results were similar in men and women.

A case report of successful long-term relapse control by protein-a immunoadsorption in an immunosuppressive-treated patient with end-stage renal disease due to Wegener's granulomatosis.

A long‐term female hemodialysis patient with end‐stage renal disease due to Wegeners granulomatosis (WG) experienced a severe relapse when immunosuppressive therapy was switched from prednisone and cyclophosphamide to azathioprine maintenance therapy. Ten courses of protein A immunoadsorption therapy and switching immunosuppressive therapy to mycophenolate mofetil have proved to be very successful and free of side effects. The patient has fully recovered from all clinical WG symptoms and is still in remission ten months after the treatment.