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Anneke Kramer,
Kitty J Jager,
Damian G Fogarty,
Pietro Ravani, Patrik Finne,
Jordi Pérez-Panadés,
Karl G Prütz,
Manuel Arias,
James G Heaf,
Christoph Wanner,
Vianda S Stel
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ABSTRACT: Background Previous studies have found inconsistent associations between pre-transplant dialysis modality and subsequent post-transplant survival. We aimed to examine this relationship using the instrumental variable method and to compare the results with standard Cox regression. Methods We included 29 088 patients (age >20 years) from 16 European national or regional renal registries who received a first kidney transplant between 1 January 1999 and 31 December 2008 and were on dialysis before transplantation for a period between 90 days and 10 years. Standard multivariable Cox regression examined the association of individually assigned pre-transplant dialysis modality with post-transplant patient and graft survival. To decrease confounding-by-indication through unmeasured factors, we applied the instrumental variable method that used the case-mix adjusted centre percentage of peritoneal dialysis (PD) as predictor variable. Results Standard analyses adjusted for age, sex, primary renal disease, donor type, duration of dialysis, year of transplantation and country suggested that PD before transplantation was associated with better patient [hazard ratio, HR (95% CI) = 0.83 (0.76-0.91)] and graft survival (HR (95% CI) 0.90 (0.84-0.96)) when compared with haemodialysis (HD). In contrast, the instrumental variable analysis showed that a 10% increase in the case-mix adjusted centre percentage of patients on PD was neither associated with post-transplant patient survival [HR (95% CI = 1.00 (0.97-1.04)] nor with graft survival [HR (95% CI) = 1.01 (0.98-1.04)]. Conclusions The instrumental variable method failed to confirm the associations found in standard Cox regression between pre-transplant dialysis modality and patient and graft survival after transplantation. The lack of association in instrumental variable analysis may be due to better control of residual confounding.
Nephrology Dialysis Transplantation 12/2012; 27(12):4473-80. · 3.40 Impact Factor
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ABSTRACT: Background: Atherosclerosis is an important predictor of mortality in patients with end-stage renal disease. The aim of this study was to determine how various vascular comorbidities such as coronary heart disease (CHD), peripheral vascular disease (PVD) or cerebrovascular disease (CeVD) affect survival of type 2 diabetic patients on renal replacement therapy (RRT). Methods: Patients who entered RRT because of type 2 diabetes in 2000-2008 (n = 877) were identified within the Finnish Registry for Kidney Diseases. The patients were followed up until death or end of follow-up. Survival probabilities were calculated using Kaplan-Meier curves. Multivariate modeling was performed using Cox regression. Results: 41% of the patients had CHD, 27% PVD and 16% CeVD at the start of RRT. Patients with PVD had a 1.9-fold (95% CI 1.6-2.3) risk of death compared to those without PVD when adjusting for age and gender, while patients with CHD had a 1.5-fold (95% CI 1.2-1.8) and those with CeVD a 1.4-fold (95% CI 1.1-1.8) risk compared to those without these diseases. The hazard ratio (HR) for death was highest in patients with the combination of PVD and either CHD (HR 2.8, 95% CI 2.1-3.8) or CeVD (HR 2.9, 95% CI 1.6-5.2) as compared to patients without any vascular comorbidities. Conclusion: PVD is the vascular comorbidity that increases risk of death the most among patients with type 2 diabetes starting RRT. Prevention of PVD in this patient group would merit further studies.
American Journal of Nephrology 11/2012; 36(6):509-515. · 2.54 Impact Factor
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Moniek W M van de Luijtgaarden,
Marlies Noordzij,
Charles Tomson,
Cécile Couchoud,
Giovanni Cancarini,
David Ansell,
Willem-Jan W Bos,
Friedo W Dekker,
Jose L Gorriz,
Christos Iatrou,
Liliana Garneata,
Christoph Wanner,
Svjetlana Cala,
Olivera Stojceva-Taneva, Patrik Finne,
Vianda S Stel,
Wim van Biesen,
Kitty J Jager
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ABSTRACT: BACKGROUND: Little is known about the criteria nephrologists use in the decision of when to start renal replacement therapy (RRT) in early referred adult patients. We evaluated opinions of European nephrologists on the decision for when to start RRT. STUDY DESIGN: European web-based survey. PREDICTORS: Patient presentations described as uncomplicated patients, patients with unfavorable clinical and unfavorable social conditions, or patients with specific clinical, social, and logistical factors. SETTING & PARTICIPANTS: Nephrologists from 11 European countries. OUTCOMES & MEASUREMENTS: We studied opinions of European nephrologists about the influence of clinical, social, and logistical factors on decision making regarding when to start RRT, reflecting practices in place in 2009. Questions included target levels of kidney function at the start of RRT and factors accelerating or postponing RRT initiation. Using linear regression, we studied determinants of target estimated glomerular filtration rate (eGFR) at the start of RRT. RESULTS: We received 433 completed surveys. The median target eGFR selected to start RRT in uncomplicated patients was 10.0 (25th-75th percentile, 8.0-10.0) mL/min/1.73 m(2). Level of excretory kidney function was considered the most important factor in decision making regarding uncomplicated patients (selected by 54% of respondents); in patients with unfavorable clinical versus social conditions, this factor was selected by 24% versus 32%, respectively. Acute clinical factors such as life-threatening hyperkalemia refractory to medical therapy (100%) and uremic pericarditis (98%) elicited a preference for an immediate start, whereas patient preference (69%) and vascular dementia (66%) postponed the start. Higher target eGFRs were reported by respondents from high- versus low-RRT-incidence countries (10.4 [95% CI, 9.9-10.9] vs 9.1 mL/min/1.73 m(2)) and from for-profit versus not-for-profit centers (10.1 [95% CI, 9.5-10.7] vs 9.5 mL/min/1.73 m(2)). LIMITATIONS: We were unable to calculate the exact response rate and examined opinions rather than practice for 433 nephrologists. CONCLUSIONS: Only for uncomplicated patients did half the nephrologists consider excretory kidney function as the most important factor. Future studies should assess the weight of each factor affecting decision making.
American Journal of Kidney Diseases 08/2012; · 5.43 Impact Factor
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Johanna Temme,
Anneke Kramer,
Kitty J Jager,
Katharina Lange,
Frederick Peters,
Gerhard-Anton Müller,
Reinhard Kramar,
James G Heaf, Patrik Finne,
Runolfur Palsson, [......],
Andries J Hoitsma,
Wendy Metcalfe,
Maurizio Postorino,
Oscar Zurriaga,
Julio P Santos,
Pietro Ravani,
Faical Jarraya,
Enrico Verrina,
Friedo W Dekker,
Oliver Gross
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ABSTRACT: Background and objectives Patients with the hereditary disease Alport syndrome commonly require renal replacement therapy (RRT) in the second or third decade of life. This study compared age at onset of RRT, renal allograft, and patient survival in men with Alport syndrome receiving various forms of RRT (peritoneal dialysis, hemodialysis, or transplantation) with those of men with other renal diseases. Design, setting, participants, & measurements Patients with Alport syndrome receiving RRT identified from 14 registries in Europe were matched to patients with other renal diseases. A linear spline model was used to detect changes in the age at start of RRT over time. Kaplan-Meier method and Cox regression analysis were used to examine patient and graft survival. Results Age at start of RRT among patients with Alport syndrome remained stable during the 1990s but increased by 6 years between 2000–2004 and 2005–2009. Survival of patients with Alport syndrome requiring dialysis or transplantation did not change between 1990 and 2009. However, patients with Alport syndrome had better renal graft and patient survival than matched controls. Numbers of living-donor transplantations were lower in patients with Alport syndrome than in matched controls. Conclusions These data suggest that kidney failure in patients with Alport syndrome is now being delayed compared with previous decades. These patients appear to have superior patient survival while undergoing dialysis and superior patient and graft survival after deceased-donor kidney transplantation compared with patients receiving RRT because of other causes of kidney failure.
Clinical Journal of the American Society of Nephrology 01/2012; 7. · 5.23 Impact Factor
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ABSTRACT: Associations between mode of renal replacement therapy and employment rate have not been well characterized.
Cross-sectional registry analysis.
The employment status of all prevalent 15- to 64-year-old dialysis and kidney transplant patients in Finland at the end of 2007 (N = 2,637) was analyzed by combining data from the Finnish Registry for Kidney Diseases with individual-level employment statistics of the Finnish government.
Prevalence rate ratios (PRRs) of employment according to treatment modality with adjustment for age, sex, cause of end-stage renal disease (ESRD), duration of ESRD, and comorbid conditions were estimated using Cox regression with a constant time at risk.
Employment status of patients on dialysis therapy or after transplant.
Clinical data were collected from the Finnish Registry for Kidney Diseases, and employment data were acquired from Statistics Finland.
19% of hemodialysis patients, 31% of peritoneal dialysis patients, and 40% of patients with a functioning transplant were employed; the overall employment rate for the Finnish population aged 15-64 years is 67%. Home hemodialysis patients and those treated with automated peritoneal dialysis had employment rates of 39% and 44%, respectively. In adjusted analysis, patients on home hemodialysis therapy (PRR, 1.87), on automated peritoneal dialysis therapy (PRR, 2.14), or with a kidney transplant (PRR, 2.30) had higher probabilities of employment than in-center hemodialysis patients. Patients with type 1 or 2 diabetes as the cause of ESRD had the lowest probability of employment (PRR, 0.48-0.60 compared with glomerulonephritis). Patients aged 25-54 years more frequently were employed than those younger than 25 or older than 54 years. Sex did not predict employment. For transplant recipients, longer time since transplant was associated with higher employment in addition to the mentioned factors.
Cross-sectional design.
Employment rate of home dialysis patients was similar to that of transplant recipients and higher than that of in-center hemodialysis patients. Patients with diabetes were less likely to be employed.
American Journal of Kidney Diseases 09/2011; 59(5):700-6. · 5.43 Impact Factor
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ABSTRACT: Estimated glomerular filtration rate (eGFR) is widely used in follow-up and assessment of patients before start of chronic renal replacement therapy (RRT). Reported data on impact of eGFR decline pattern during pre-dialysis phase on consequent survival on RRT are, however, non-existent.
Using the database of the Finnish Registry for Kidney Diseases, we conducted a cohort study of all incident adult patients (n = 457) entering chronic RRT in Finland in 1998, with follow-up until 31 December 2008. We included those (n = 319) with three serum creatinine measurements (at ∼12 and 3 months and 1 to 2 weeks prior to RRT start) and calculated their slopes of eGFR using the modification of diet in renal disease formula. According to eGFR slopes (in mL/min/1.73m(2)/year), patients were divided into tertiles: most rapid (>8.5, n = 107), intermediate (3.4-8.5, n = 107) and slowest decline (<3.4, n = 105).
Median survival time was 5.6 (95% confidence interval 4.2-7.0) years. Compared to the patient group with the slowest eGFR decline, age- and gender-adjusted relative risk of death was 1.1 (0.8-1.5) in the intermediate group and 1.7 (1.2-2.4, P = 0.002) in the most rapid decline group. When further adjusting for kidney disease diagnosis, comorbidities, use of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, body mass index, blood haemoglobin and serum albumin, the association was no longer significant.
Rapid decline in eGFR before entering chronic RRT associates with increased mortality on RRT. The elevated mortality appears to be caused by known risk factors for death on RRT.
Nephrology Dialysis Transplantation 08/2011; 27(3):1157-63. · 3.40 Impact Factor
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Juan J Carrero,
Dinanda J de Jager,
Marion Verduijn,
Pietro Ravani,
Johan De Meester,
James G Heaf, Patrik Finne,
Andries J Hoitsma,
Julio Pascual,
Faiçal Jarraya,
Anna V Reisaeter,
Frederic Collart,
Friedo W Dekker,
Kitty J Jager
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ABSTRACT: Although women have a survival advantage in the general population, women on dialysis have similar mortality to men. We hypothesized that this paired mortality risk during dialysis may be explained by a relative excess of cardiovascular-related mortality in women.
We compared 5-year age-stratified cardiovascular and noncardiovascular mortality rates, relative risks, and hazard ratios in a European cohort of incident adult dialysis patients (European Renal Association-European Dialysis and Transplant Association [ERA-EDTA] Registry) with the European general population (Eurostat). Cause of death was recorded by ERA-EDTA codes in dialysis patients and by International Statistical Classification of Diseases codes in the general population.
Overall, sex did not have a predictive effect on outcome in dialysis. Stratification into age categories and causes of death showed greater noncardiovascular mortality in young women (<45 years). In other age categories (45 to 55 and >55 years), women presented lower cardiovascular mortality. This cardiovascular benefit was, however, smaller than in the general population. Stratification by diabetic nephropathy showed that diabetic women in all age categories remained at increased mortality risk compared with men, an effect mainly attributed to the noncardiovascular component.
Mortality rates and causes of death in men and women on dialysis vary with age. Increased noncardiovascular mortality may explain the loss of the survival advantage of women on dialysis. Both young and diabetic women starting dialysis are at a higher mortality risk than equal men.
Clinical Journal of the American Society of Nephrology 07/2011; 6(7):1722-30. · 5.23 Impact Factor
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ABSTRACT: Risk for amyloidosis in rheumatic diseases is associated with a long-lasting inflammation. To assess possible changes in the incidence of terminal uraemia due to amyloidosis associated with rheumatic diseases on a nationwide basis, we scrutinised the files of the Finnish Registry for Kidney Diseases for patients suffering from amyloidosis associated with rheumatoid arthritis (RA), ankylosing spondylitis (AS) or juvenile idiopathic arthritis (JIA) over the period 1995-2008. The registry has an estimated 97-99% coverage of all patients accepted for renal replacement therapy (RRT) in the country. Data on the consumption of antirheumatic drugs were collected from two sources: the Social Insurance Institution's Drug Reimbursement Register, and the Sales Register of the National Agency for Medicines from the above period. Altogether 264 cases were identified. Two hundred twenty-nine of them had RA, 15 AS and 20 JIA. When the total annual number of new admissions to RRT varied between 20 and 37 at the end of 1990s, it was under half of that from 2002 onwards. Over this period, the number of users of low-dose methotrexate (MTX) has increased 3.6-fold, the drug being the most frequently used disease modifying anti-rheumatic drug in Finland. The present nationwide series is the first to show that the incidence of end-stage renal disease due to amyloidosis associated with rheumatic diseases is decreasing. An obvious reason for this is intensive anti-rheumatic drug therapy.
Amyloid: the international journal of experimental and clinical investigation: the official journal of the International Society of Amyloidosis 03/2011; 18(1):25-8. · 2.12 Impact Factor
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ABSTRACT: Prediction models need external validation to assess their value beyond the setting where the model was derived from.
To assess the external validity of the European Randomized study of Screening for Prostate Cancer (ERSPC) risk calculator (www.prostatecancer-riskcalculator.com) for the probability of having a positive prostate biopsy (P(posb)).
The ERSPC risk calculator was based on data of the initial screening round of the ERSPC section Rotterdam and validated in 1825 and 531 men biopsied at the initial screening round in the Finnish and Swedish sections of the ERSPC respectively. P(posb) was calculated using serum prostate specific antigen (PSA), outcome of digital rectal examination (DRE), transrectal ultrasound and ultrasound assessed prostate volume.
The external validity was assessed for the presence of cancer at biopsy by calibration (agreement between observed and predicted outcomes), discrimination (separation of those with and without cancer), and decision curves (for clinical usefulness).
Prostate cancer was detected in 469 men (26%) of the Finnish cohort and in 124 men (23%) of the Swedish cohort. Systematic miscalibration was present in both cohorts (mean predicted probability 34% versus 26% observed, and 29% versus 23% observed, both p<0.001). The areas under the curves were 0.76 and 0.78, and substantially lower for the model with PSA only (0.64 and 0.68 respectively). The model proved clinically useful for any decision threshold compared with a model with PSA only, PSA and DRE, or biopsying all men. A limitation is that the model is based on sextant biopsies results.
The ERSPC risk calculator discriminated well between those with and without prostate cancer among initially screened men, but overestimated the risk of a positive biopsy. Further research is necessary to assess the performance and applicability of the ERSPC risk calculator when a clinical setting is considered rather than a screening setting.
European journal of cancer (Oxford, England: 1990) 12/2010; 47(6):903-9. · 4.12 Impact Factor
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ABSTRACT: Lead-time is defined as the time by which screening advances the diagnosis compared with absence of screening. A sufficiently long lead-time needs to be achieved so that cancer can be detected while still curable. A very short lead-time may indicate poor sensitivity of the screening test, while a very long lead-time suggests overdiagnosis.
In the first screening round, a total of 56,294 men aged 55-74 years were screened with serum prostate specific antigen (PSA) in five countries of the European Randomised Study of Screening for Prostate Cancer (ERSPC) with an overall detection rate (prevalence) of 2.8% (1972 prostate cancers). Prostate cancer incidence among 92,142 men randomly allocated to the control arm of the trial was also assessed. Lead-time was estimated as the time required to accumulate a similar cumulative risk of prostate cancer in the control arm to the detection rate in the intervention arm, i.e. from the ratio of detection rate (prevalence of screen-detected cases) and expected incidence (cumulative risk).
Using a serum PSA cut-off of 4 ng/ml, the mean lead-time in the whole study population was estimated as 6.8 years (95% confidence interval (95% CI) 7.9-8.4). It was 8 years in The Netherlands, 6 in Sweden and Finland, 5 in Italy and 4 in Belgium. The mean lead-time was similar, 6-7 years, at ages 50-64 years, but close to 8 years among men aged 65-74 years. A lower PSA cut-off level of 3 ng/ml used in Sweden and The Netherlands prolonged the mean lead-time by approximately 1 year. Lead-time based on advanced prostate cancer only was slightly shorter, mean 5.3 years (95% CI 4.6-6.0). The lead-time for the second screening round was slightly shorter than that for the first (5.9, 95% CI 5.4-6.4), reflecting a similar relation between detection rate and control group incidence.
The lead-time for prostate cancer found in ERSPC substantially exceeded that found for breast, cervical and colorectal cancer screening. One round of prostate cancer screening can advance clinical diagnosis by 4-8 years. Overdiagnosis or detection of non-progressive tumours may contribute substantially to the lead-time.
European journal of cancer (Oxford, England: 1990) 11/2010; 46(17):3102-8. · 4.12 Impact Factor
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Vianda S Stel,
Charles Tomson,
David Ansell,
Francesco G Casino,
Frederic Collart, Patrik Finne,
George A Ioannidis,
Johan De Meester,
Mario Salomone,
Jamie P Traynor,
Oscar Zurriaga,
Kitty J Jager
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ABSTRACT: The aims of this European study were (i) to compare the level of renal function at the start of dialysis between age groups, gender, primary renal disease, comorbid conditions, treatment modality, time periods and countries, and (ii) to determine which baseline characteristics are associated with the level of renal function at the start of dialysis.
Renal registries participating in the European Renal Association-European Dialysis and Transplant Association Registry provided data on serum creatinine 0-4 weeks before the start of dialysis in incident dialysis patients in 1999 and 2003. Data were available in 11 472 patients from nine renal registries. Glomerular filtration rate (GFR) was estimated by the four-variable Modification of Diet in Renal Disease equation.
The unadjusted median eGFR at the start of dialysis was 7.0 mL/min/1.73 m(2) in the 1999 data (median serum creatinine 7.5 mg/dL) and 7.7 mL/min/1.73 m(2) in the 2003 data (serum creatinine 7.0 mg/dL). Using linear regression with adjustment for the other covariates, older patients, males, patients with diabetes mellitus, hypertension/renal vascular disease (HT/RVD) as primary renal disease (vs glomerulonephritis), ischaemic heart disease or peripheral vascular disease and patients starting on peritoneal dialysis (PD) initiated dialysis at higher levels of eGFR (range Δ eGFR: 0.1-1.2 mL/min/1.73 m(2)). Using the same analyses, eGFR differed between countries (range: 6.5-8.6 mL/min/1.73 m(2)).
During 2003, patients started dialysis at somewhat higher eGFR levels than those starting during 1999. There were also international differences in eGFR. Such differences may, at least in part, be explained by differences in creatinine measurement methods between countries and time periods. Finally, older patients, males, patients with HT/RVD or comorbidity and those starting on PD had slightly higher eGFR levels than younger patients, females, those with glomerulonephritis, without comorbidity and those starting on haemodialysis. Further research is needed into other, more clinically related factors affecting the decision to start dialysis.
Nephrology Dialysis Transplantation 10/2010; 25(10):3315-25. · 3.40 Impact Factor
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ABSTRACT: Risks of end-stage renal disease and premature death in patients with type 1 diabetes have declined over the past decades. Data on the survival of patients receiving renal replacement therapy (RRT) are, however, limited. We investigated whether survival of patients with type 1 diabetes receiving RRT has improved over time and whether improvement can be attributable to progress in dialysis treatment or diabetes care.
An incident cohort of all patients with type 1 diabetes (n = 1,604) starting chronic RRT in Finland between 1980 and 2005 were followed until death or end of follow-up on 31 December 2007. The control group (n = 1,556) consisted of patients with glomerulonephritis who started RRT. All patients were identified from the Finnish Registry for Kidney Diseases.
Median survival time of patients with type 1 diabetes increased progressively from 3.60 years during 1980-1984 to >8 years in 2000-2005. In 2000-2005, the unadjusted relative risk of death was 0.55 compared with 1980-1984. After adjustment for the most important variables, the corresponding relative risk of death was only 0.23. For patients with glomerulonephritis, the adjusted relative risk decreased to a lesser extent to 0.30 (P = 0.007).
Survival of patients with type 1 diabetes and end-stage renal disease has improved since the 1980s despite a conspicuous increase in the age of patients who start RRT, suggesting not only true progress in dialysis therapy and overall treatment of patients with end-stage renal disease but possibly also improved management of diabetes.
Diabetes care 08/2010; 33(8):1718-23. · 8.09 Impact Factor
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ABSTRACT: Information on demographics and survival of patients starting renal replacement therapy (RRT) for end-stage renal disease (ESRD) due to multiple myeloma (MM) or light-chain deposit disease (LCDD) is scarce. The aim of this study was to describe the incidence, characteristics, causes of death and survival rates of RRT for ESRD due to MM or LCDD in the ERA-EDTA Registry.
Thirteen national registries providing data on patients who started RRT from 1986-2005 to the ERA-EDTA Registry participated. Incidence per million population (pmp) of RRT for ESRD due to MM or LCDD and other causes (non-MM) was observed overtime. Patient survival on RRT was examined, unadjusted and adjusted for age and gender.
Of the 159 637 patients on RRT, 2453 (1.54%) had MM or LCDD. The incidence of RRT for ESRD due to MM or LCDD, adjusted for age and gender, increased from 0.70 pmp in 1986-1990 to 2.52 pmp in 2001-2005. MM and LCDD patients compared to non-MM patients were older and a higher percentage was on haemodialysis at day 91 after the start of RRT. The most common causes of death in MM and LCDD patients were malignancy (36.1%), cardiovascular causes (17.2%) and infection (14.7%). MM and LCDD patients had a 2.77 (95% CI, 2.65-2.90) higher risk of death compared to non-MM patients. The unadjusted median survival on RRT was 0.91 years in MM and LCDD patients and 4.46 years in non-MM patients. During follow-up, 35 patients were transplanted and their mean survival was 9.6 years.
The incidence of RRT for ESRD due to MM or LCDD has increased over the past 20 years in Europe. The median patient survival on RRT for MM and LCDD patients was 0.91 years, compared to 4.46 years for non-MM patients. These results suggest that dialysis, and in selected cases even transplantation, should be offered to MM and LCDD patients.
Nephrology Dialysis Transplantation 04/2010; 25(4):1200-6. · 3.40 Impact Factor
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ABSTRACT: Survival of type 2 diabetes mellitus patients on maintenance dialysis therapy is poor mainly due to cardiovascular events. The aim was to examine whether survival of type 2 diabetes patients on renal replacement therapy (RRT) in Finland has improved during 1995-2005.
Patients who entered RRT because of type 2 diabetes mellitus in 1995-99 (n = 314) and 2000-05 (n = 583) were identified within the Finnish Registry for Kidney Diseases. The two cohorts were followed up from start of RRT until death or end of follow-up on 31 December 2006. Survival probabilities and probabilities of receiving a kidney transplant were calculated using Kaplan-Meier curves. Multivariate modelling was performed using Cox regression.
Patients who entered RRT in 2000-05 had lower risk of dying than those who entered in 1995-99; hazard ratio (HR) was 0.76 (95% CI 0.65-0.89) and 0.74 (95% CI 0.63-0.87) with adjustment for age and gender. The decreased risk of death was most obvious in age groups 55-64 (HR 0.67, 95% CI 0.49-0.92) and 65-74 years (HR 0.69, 95% CI 0.56-0.87). Adjustment for albumin in addition to age and gender only slightly weakened the effect of study periods (HR 0.83, 95% CI 0.69-1.01). The patients in 2000-05 were more obese, had lower total and LDL cholesterol and higher HDL cholesterol and albumin concentration in serum than patients in 1995-99. Patients' probability to receive a kidney transplant was low in both groups.
Survival of type 2 diabetes patients on RRT improved during the time period 1995-2005 in Finland while the probability of receiving a kidney transplant remained low and unchanged.
Nephrology Dialysis Transplantation 10/2009; 25(3):892-6. · 3.40 Impact Factor
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Dinanda J de Jager,
Diana C Grootendorst,
Kitty J Jager,
Paul C van Dijk,
Lonneke M J Tomas,
David Ansell,
Frederic Collart, Patrik Finne,
James G Heaf,
Johan De Meester,
Jack F M Wetzels,
Frits R Rosendaal,
Friedo W Dekker
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ABSTRACT: Cardiovascular mortality is considered the main cause of death in patients receiving dialysis and is 10 to 20 times higher in such patients than in the general population.
To evaluate if high overall mortality in patients starting dialysis is a consequence of increased cardiovascular mortality risk only or whether noncardiovascular mortality is equally increased.
Using data from between January 1, 1994, and January 1, 2007, age-stratified mortality in a European cohort of adults starting dialysis and receiving follow-up for a mean of 1.8 (SD, 1.1) years (European Renal Association-European Dialysis and Transplant Association [ERA-EDTA] Registry [N = 123,407]) was compared with the European general population (Eurostat).
Cause of death was recorded by ERA-EDTA codes in patients and matching International Statistical Classification of Diseases, 10th Revision codes in the general population. Standardized cardiovascular and noncardiovascular mortality rates, their ratio, difference, and relative excess of cardiovascular over noncardiovascular mortality were calculated.
Overall all-cause mortality rates in patients and the general population were 192 per 1000 person-years (95% confidence interval [CI], 190-193) and 12.055 per 1000 person-years (95% CI, 12.05-12.06), respectively. Cause of death was known for 90% of the patients and 99% of the general population. In patients, 16,654 deaths (39%) were cardiovascular and 21,654 (51%) were noncardiovascular. In the general population, 7,041,747 deaths (40%) were cardiovascular and 10,183,322 (58%) were noncardiovascular. Cardiovascular and noncardiovascular mortality rates in patients were respectively 38.1 per 1000 person-years (95% CI, 37.2-39.0) and 50.1 per 1000 person-years (95% CI, 48.9-51.2) higher than in the general population. On a relative scale, standardized cardiovascular and noncardiovascular mortality were respectively 8.8 (95% CI, 8.6-9.0) and 8.1 (95% CI, 7.9-8.3) times higher than in the general population. The ratio of these rates, ie, relative excess of cardiovascular over noncardiovascular mortality in patients starting dialysis compared with the general population, was 1.09 (95% CI, 1.06-1.12). Relative excess in a sensitivity analysis in which unknown/missing causes of death were regarded either as noncardiovascular or cardiovascular varied between 0.90 (95% CI, 0.88-0.93) and 1.39 (95% CI, 1.35-1.43).
Patients starting dialysis have a generally increased risk of death that is not specifically caused by excess cardiovascular mortality.
JAMA The Journal of the American Medical Association 10/2009; 302(16):1782-9. · 30.03 Impact Factor
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Vianda S Stel,
Friedo W Dekker,
David Ansell,
Hans Augustijn,
Francesco G Casino,
Frederic Collart, Patrik Finne,
George A Ioannidis,
Mario Salomone,
Jamie P Traynor,
Oscar Zurriaga,
Enrico Verrina,
Kitty J Jager
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ABSTRACT: This study evaluates the association between estimated GFR (eGFR) at the start of dialysis and mortality within Europe.
Renal registries participating in the ERA-EDTA Registry were asked to provide data on serum creatinine recorded 0-4 weeks before the start of dialysis in incident dialysis patients in 1999 and 2003. Within this cohort study, data were available in 11 472 patients from nine national or regional European renal registries. Cox regression analyses were performed to examine the association between GFR estimated by the four-variable MDRD equation (eGFR) and all-cause mortality, using a follow-up through 31 December 2005.
In the 2003 data, the mean eGFR was 8.6 ml/min/1.73 m(2). The unadjusted survival analyses showed that an increase in eGFR of 1 ml/min/1.73 m(2) was associated with a higher mortality risk (HR = 1.03; 95% CI: 1.03-1.04) that remained similar after adjustment for age, gender, primary renal disease, treatment modality, country and comorbidity. The findings were consistent across gender, treatment modalities, geographical regions and time periods (2003 versus 1999), but the association between a higher eGFR at the start of dialysis and mortality was the strongest in the youngest age groups and in patients with glomerulonephritis. Analyses at centre level showed that a 10% increase in the percentage of patients starting dialysis at high eGFR levels (>or=10.5 ml/min) was associated with a 22% higher mortality risk (HR = 1.22; 95% CI: 1.18-1.26).
This European study showed that a higher eGFR at the start of dialysis was associated with a higher mortality risk. However, an answer to the question when to start dialysis needs to come from randomized controlled trials.
Nephrology Dialysis Transplantation 06/2009; 24(10):3175-82. · 3.40 Impact Factor
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Cécile Couchoud,
Kitty J Jager,
Charlie Tomson,
Jean-François Cabanne,
Frederic Collart, Patrik Finne,
Angel de Francisco,
Luc Frimat,
Liliana Garneata,
Torbjørn Leivestad,
Vincent Lemaitre,
Aurelio Limido,
Mai Ots,
Halima Resic,
Olivera Stojceva-Taneva,
Jeroen Kooman
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ABSTRACT: Dialysis adequacy, assessed by urea kinetics, is an important determinant of patient outcome, and is therefore an important clinical performance indicator. In this perspective, renal registry data may be useful to compare practices across countries. To serve that purpose available data should be comparable and preferably collected using a standardized procedure. The aim of this study, initiated by the European Renal Association-European Dialysis and Transplantation Association (ERA-EDTA) QUality European STudies (QUEST) initiative, was to make an inventory of the different methods used to determine urea kinetic measurements in the light of the European Best Practice Guidelines.
Via their national and regional registries, European haemodialysis centres were invited to complete a questionnaire regarding their practice of measuring dialysis adequacy.
Fourteen regional or national registries among 51 sent back 255 questionnaires. Great variability in the methodology to assess Kt/V was observed. The urea reduction ratio (URR) was used alone by 37% (in association 46%) of dialysis centres, spKt/V by 25% (35%) and on-line clearance by 4% (12%), whereas only 10% (13%) used eKt/V, as recommended by EBPG. Forty percent of centres measured urea removal less than once a month, 6% of which never measured urea removal and 9% only every 6 months or less frequently.
Despite the fact that the use of URR is not recommended by EBPG, it was the most commonly used indicator to measure urea removal, whereas eKt/V was only used by a small minority of centres. This study allowed us to point out the need to standardize definitions and procedures and to develop an effective plan for implementation of the guidelines.
Nephrology Dialysis Transplantation 12/2008; 24(4):1267-74. · 3.40 Impact Factor
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ABSTRACT: To assess the incidence and outcome of renal replacement therapy (RRT) among patients with amyloidosis associated with inflammatory rheumatic diseases.
Patients with amyloidosis entering RRT from 1987 to 2002 were identified from the Finnish Registry for Kidney Diseases. Five hundred two patients were identified, 80% of whom had amyloidosis associated with an underlying rheumatic disease. They were followed from the time of entering RRT until death or until the end of 2003 using the Finnish national mortality files.
During the study period, there was no decline in the number of patients with amyloidosis entering RRT. Mean age of patients with rheumatoid arthritis (RA) and juvenile idiopathic arthritis (JIA) increased significantly from 1987 to 2002 (p < 0.001). Male sex and a diagnosis of JIA indicated an increased risk of mortality. The median survival time after entering RRT was 2.11 years for RA (95% CI 1.93 to 2.69), 2.37 years for ankylosing spondylitis (95% CI 1.11 to 4.31), and 3.05 years for JIA (95% CI 2.19 to 4.23). The 5-year survival rates among patients with the corresponding diagnoses were 18% (95% CI 14% to 23%), 30% (95% CI 14% to 48%), and 27% (95% CI 14% to 41%), respectively.
No decline was seen in the number of patients with amyloidosis associated with inflammatory rheumatic diseases accepted for RRT, but over the years, the age of patients with RA or JIA entering RRT was seen to increase. The outcome of patients with amyloidosis and endstage renal disease associated with rheumatic diseases remains poor.
The Journal of Rheumatology 08/2008; 35(7):1334-8. · 3.69 Impact Factor
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ABSTRACT: The percentage of free prostate-specific antigen (%fPSA) improves the diagnostic accuracy for prostate cancer when the serum level of total PSA (tPSA) is elevated. Approximately 14% of men with a tPSA below 3 microg/l have prostate cancer on biopsy, but the diagnostic value of %fPSA in such men is rather unknown. The purpose was to estimate the impact of %fPSA on future prostate cancer risk among men with a normal tPSA in prostate cancer screening.
The first round of the Finnish arm of the European Randomized Trial for Screening of Prostate Cancer in 1996 to 1999 comprised 20,793 men aged 55-67 yr. Screen-negative men (tPSA level below 3.0 microg/l, n=17,680) were followed up until the end of 2003. Cumulative risk of prostate cancer was calculated as a function of %fPSA.
During the median follow-up of 5.8 yr (range, 0-7.7 yr), 327 men were diagnosed with prostate cancer and 25% of them had a Gleason score of 7 or higher. Five years after the first screening, cumulative risk of prostate cancer was 1.7% (95%CI, 1.5-1.9%). Men with a %fPSA in the lowest quartile (<14.2%) showed a 6.9-fold risk compared with those with a level in the highest quartile (>23.7%).
In men with a low serum tPSA, a low %fPSA is a strong predictor of later diagnosis of prostate cancer.
European urology 08/2008; 54(2):362-70. · 7.67 Impact Factor
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ABSTRACT: The purpose of this study was to investigate haemodialysis (HD) dose practice patterns in different European countries in the light of the European Best Practice Guidelines (EBPG) and to study the associations of patient characteristics and country with weekly dialysis duration.
Renal registries in Europe were asked to contribute to the study with individual patient data on weekly HD duration, number of HD sessions a week and last measured Kt/V. Additional items were age, sex, date of first renal replacement therapy (RRT), dry weight, height, HD modality, HD technique, diabetes status and vascular access type. Multivariate logistic regression was used to study the probability of receiving HD for <12 h per week.
Seven registries contributed data on 26 136 patients on HD on 31 December 2005. Eighty-three percent of the patients received HD for at least 12 h per week as recommended by the EBPG (range 49.0-97.3% across countries). Multivariate analysis showed significant differences across countries concerning the risk of receiving <12 h. Other risk factors included age (older), sex (female), BMI (low) and duration of RRT (shorter). Diabetes was associated with longer total HD duration.
This study shows a great international variability in weekly HD duration and some discrepancies between current practices and the EBPG. It also points out the difficulty of obtaining and comparing Kt/V values under current registry practices.
Nephrology Dialysis Transplantation 08/2008; 24(1):217-24. · 3.40 Impact Factor
