Ülle Pechter

Renal replacement therapy in Europe: a summary of the 2012 ERA-EDTA Registry Annual Report

Background This article summarizes the 2012 European Renal Association—European Dialysis and Transplant Association Registry Annual Report (available at www.era-edta-reg.org) with a specific focus on older patients (defined as ≥65 years). Methods Data provided by 45 national or regional renal registries in 30 countries in Europe and bordering the Mediterranean Sea were used. Individual patient level data were received from 31 renal registries, whereas 14 renal registries contributed data in an aggregated form. The incidence, prevalence and survival probabilities of patients with end-stage renal disease (ESRD) receiving renal replacement therapy (RRT) and renal transplantation rates for 2012 are presented. Results In 2012, the overall unadjusted incidence rate of patients with ESRD receiving RRT was 109.6 per million population (pmp) (n = 69 035), ranging from 219.9 pmp in Portugal to 24.2 pmp in Montenegro. The proportion of incident patients ≥75 years varied from 15 to 44% between countries. The overall unadjusted prevalence on 31 December 2012 was 716.7 pmp (n = 451 270), ranging from 1670.2 pmp in Portugal to 146.7 pmp in the Ukraine. The proportion of prevalent patients ≥75 years varied from 11 to 32% between countries. The overall renal transplantation rate in 2012 was 28.3 pmp (n = 15 673), with the highest rate seen in the Spanish region of Catalonia. The proportion of patients ≥65 years receiving a transplant ranged from 0 to 35%. Five-year adjusted survival for all RRT patients was 59.7% (95% confidence interval, CI: 59.3–60.0) which fell to 39.3% (95% CI: 38.7–39.9) in patients 65–74 years and 21.3% (95% CI: 20.8–21.9) in patients ≥75 years.

Beneficial effects of water-based exercise in patients with chronic kidney disease.

The possible beneficial effect of regular aquatic exercise on cardiorespiratory, renal lipid parameters and oxidative stress status was studied in patients with mild to moderate renal failure. The exercise group did low-intensity aerobic exercise in the pool during a period of 12 weeks, twice a week, with sessions lasting for 30 min. Matched control participants remained sedentary. The results showed that in the exercise group all cardiorespiratory functional parameters improved and resting blood pressure lowered significantly. Proteinuria and cystatin-C were diminished significantly and glomerular filtration rate was enhanced. To evaluate the changes in oxidative stress status in the serum, products of lipid peroxidation (LPO) and serum glutathione values were measured. LPO was reduced significantly and reduced glutathione levels showed significant improvement after the exercise-conditioning programme. In the control group the data either remained the same or worsened in the same period of time. In conclusion, regular water-based exercise has beneficial effects on the cardiorespiratory, renal functional parameters and oxidative stress status in patients with moderate renal failure, and can be used in the complex rehabilitation of chronic renal failure patients, together with blood pressure control, dietary consultation, encouragement and education to prevent physical worsening and to postpone cardiovascular and renal atherosclerotic complications.

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.

Characteristics of progressive renal disease.

Virtually all renal diseases progress to terminal renal failure relatively independently of the initial disease. Arresting the rate of the deterioration of kidney failure has a great impact on reducing the number of patients reaching the stage of expensive renal replacement therapy. Understanding the mechanisms of the progression of kidney disease has greatly been improved during recent years. The nature of the progressive renal damage with various etiologies includes various well-known factors where hemodynamics, renin-angiotensin system (RAS) and progressive proteinuria play the central roles. Proteinuria has to be shown as an independent risk factor for renal disease progression. Also, disturbances in lipid metabolism as well as the later structural lesions contribute to the progression. Various modalities have been used for the prevention of progressive renal disease, e.g. low-protein diet, antihypertensive therapy, antifibrotic therapy. Many recent experimental and clinical studies have shown that besides the systemic blood pressure lowering effect, RAS blocking agents provide renal protective effects via direct, hemodynamic, and indirect, non-hemodynamic, pathways: (1) lowering intraglomerular capillary hydraulic pressure, and increasing the glomerular ultrafiltration coefficient; (2) lowering proteinuria; (3) lowering hyperlipidemia; (4) diminishing kidney growth; (5) diminishing infiltration of macrophages; (6) downregulation of proinflammatory cytokines. Therefore, RAS blocking agents are widely prescribed not only for antihypertensive but also for renoprotective purposes in diabetic and non-diabetic nephropathies.

Oxidative stress status in kidney tissue after losartan and atenolol treatment in experimental renal failure.

Background/Aims: Rats with subtotal nephrectomy (5/6NPX) rapidly develop systemic hypertension and proteinuria. The aim of our study was to evaluate the changes in oxidative stress parameters after 2 and 4 weeks of treatment with renin-angiotensin system (RAS)-blocking agent losartan and beta-blocking agent atenolol in experimental chronic renal failure (CRF). Methods: After 5/6NPX, rats were immediately treated with losartan or atenolol. The lipid peroxidation (LPO) products malondialdehyde and 4-hydroxyalkenals and oxidized and reduced glutathione values were measured in the renal cortex tissue and in blood; isoprostanes in urine. Results: There were no differences in the blood pressure values, serum creatinine levels or in daily proteinuria using both antihypertensive treatments. Losartan treatment lowered significantly LPO in kidney tissue after 2 and 4 weeks of treatment compared with untreated and atenolol-treated animals and induced the decrease of excretion of isoprostanes in urine at the end of the study. There was no ameliorating impact of losartan or atenolol observed in the blood status of oxidative stress in this period of time. Conclusion: In the early period of experimental CRF, losartan treatment but not atenolol treatment induces significant decline in LPO grade in the kidney tissue of nephrectomized rats. RAS blockade in the kidney influences local tissue LPO in a much greater extent than in blood.

Low-dose radiation modifies the progression of chronic renal failure.

Previous studies have indicated that the application of low dose radiation to an arterial ligation has the potential to subsequently reduce or eliminate restenosis caused by smooth muscle cell proliferation. Sufficient kidney irradiation causes a radiation nephropathy and often leads to renal failure. In order to evaluate the effect of low-dose irradiation on the kidney we hypothesized that this particular therapy modifies renal injury in rats with renal ablation and subsequently slows the rate of the progression. For further clarification of the effect of irradiation at low doses, we determined proliferating cell nuclear antigen (PCNA) and monocyte chemoattractant protein-1 (MCP-1) expression in remnant kidneys after low-dose radiation. Adult Wistar rats (n = 10) were studied during the two weeks after renal ablation. The left kidney was irradiated 24 hours after an operation in anaesthetised animals with 3 Grey in a single dose. Ablated rats without irradiation (n = 9) served as nephrectomized animals group. Rats without surgery and without radiation (n = 10) served as healthy controls. Renal damage was assessed using the following parameters: urine protein excretion rate (UprotV, mg/day), awake systolic blood pressure (SBP, mm Hg), serum creatinine (SCr, micromol/l). The indirect immunofluorescence method was used for the detection of PCNA and MCP-1 expression. Glomerular and tubular immunostaining was scored semiquantitatively. Numerous PCNA positive cells and MCP-1 expression were present in the glomerulus and tubulointerstitium in nephrectomized rat kidneys. Low-dose radiation application was associated with a significant reduction in PCNA and low MCP-1 expression. This study shows that the application of low-dose irradiation has the potential to modify the progression of chronic renal failure in rats.

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.

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.

Kroonilise neerupuudulikkusega haigete kompleksse taastusravi võimalusi

Taastusravi kroonilise neeruhaiguse korral holmab lisaks medikamentoossele renoprotekteerivale ravile kindlasti ka dieedisoovitusi, kehakaalu langetamise planeerimist, suitsetamisest loobumist ning moodukalt doseeritud ja regulaarset kehalist aktiivsust (liikumisravi). Kehalise aktiivsuse intensiivsus, regulaarsus ja maht tuleb valida individuaalselt igale patsiendile soltuvalt neeruhaiguse staadiumist. Eesti Arst 2003; 82 (1): 16–21