[The Veneto Region's Registry of Dialysis and Transplantation: 2006-2007 report]

F Antonucci, E Camerin, M Feriani, M Nordio, A Piccoli, B Rossi, N Tessitore
Giornale Italiano di Nefrologia: Organo Ufficiale Della Società Italiana di Nefrologia 2009, 26 Suppl 48: S5-56

INCIDENCE: Five hundred and sixty patients began renal replacement therapy in 2006, giving an incidence of 117.51 pmp; in 2007 there were 579 new patients, for an incidence rate of 120.01 pmp. Analysis of the incidence between 1998 and 2007 for both raw and age-standardized data (based on the 2001 census) shows a slow, gradual increase that is statistically significant. Most of the patients were between 55 and 85 years old; the modal class for males was between 65 and 70, and between 75 and 80 for females. The median age of the population beginning replacement therapy is clearly over 65 years old. The year 2000 was particularly significant because the incidence of new patients undergoing renal replacement therapy over the age of 75 definitively exceeded that of the next younger class (65-74 years old), a trend that remained constant until 2007. In 2006 and 2007, males account for 64.4% and 66.4%, respectively, of new patients, a proportion that is constant over the years. The greater incidence of males is also to be found across the other age groups and tends to be even more noticeable in the oldest age class. Incidence by province is highly variable, however, there is a constant trend within provinces during these years, since the incidence in some provinces is lower than the regional average and higher in others. After adjusting for age, there are no significant differences in the incidence between provinces: the age structure of the population accounts for the variability of the incidence of terminal uremia across the Veneto provinces. The conditions most responsible for renal insufficiency requiring replacement therapy are vascular diseases, diabetes and nephropathies of unknown origin. Although diabetic and vascular nephropathies are subject to wide fluctuations, they remain stable over the years, whereas the frequency of nephropathy of unknown origin appears to be on the rise. The first treatment for most of the patients is hemodialysis. In 2006, 436 patients (78%) were given extracorporeal dialysis as first treatment, compared to 122 patients (22%) who were given peritoneal dialysis and 2 (0.35%) who received live-donor kidney transplant. In 2007 the situation was very similar, with 435 patients treated with extracorporeal dialysis, 142 with peritoneal dialysis and 1 by a live-donor transplant. The proportion between patients treated with hemodialysis and peritoneal dialysis was constant from 1998 to 2007. The choice between hemodialysis or peritoneal dialysis as the initial treatment modality depends on many factors, ranging from clinical indications to cultural attitudes at the facility to individual patient preferences. Logistic regression of the factors influencing the choice of dialysis treatment shows that peritoneal dialysis is offered primarily to patients between the ages of 45 and 65 who do not have an underlying systemic or nephropathy of unknown origin and who do not have any comorbidities. This confirms the positive selection made with regard to these patients, widely described in the literature. Initial treatment by transplant is an exceptional event: starting from 2003, it was used in only 1 or 2 patients per year. Seventy-two percent of patients starting replacement therapy present with at least one comorbidity. Thirty-six percent of patients also present with more than one associated disease. The RVDT has been gathering data on the vascular access used for new dialysis patients since 2006. Roughly 43% of patients start treatment with an arteriovenous fistula, 38% with a temporary catheter, less than 1% with a prosthesis, 9% with a tunneled catheter, and 10% with a peritoneal catheter. Logistic regression was used to evaluate what role age, primary nephropathies and comorbidities present at the start of treatment play in determining the choice of a temporary catheter. The logistic model estimates a 29% probability of starting treatment with a temporary access. This probability decreases if the patient suffers from a familiar or hereditary nephropathy but increases if the patient has secondary glomerulonephritis or is affected by a group of various diseases (multiple myeloma or other pathologies) or if the patient suffers at the same time from cardiac insufficiency or an infection. The estimated probability of starting hemodialysis with a mature fistula is 40%, but this figure diminishes significantly in female patients, if the patient has secondary glomerulonephritis, cardiac insufficiency or infections.

PREVALENCE: As of December 31, 2006, there were 4,071 patients being treated with extracorporeal or peritoneal dialysis or by kidney transplant, leading to a prevalence of 852.82 patients pmp; as of December 31, 2007, there were 4,200 patients treated, with a corresponding prevalence of 869.14 pmp. The breakdown in prevalence by age group shows that the increase in prevalence is highly significant in the top two age classes, namely, between 65 and 75 years of age and over 75, while remaining negligible in the other classes. Between 1998 and 2007, the prevalence increased by 40% in patients over 75 and increased by 20% in the class of 65-to-75 year olds. The elderly contribute a greater weight in the renal replacement therapy population, reflected in the gradual increase of the median age of the prevalent population from 1998 to 2007. During 2006 and 2007, males made up 63.99% and 64.36% of the patients, respectively. This relative frequency mirrors the findings for incidence and is constant over the years. The distribution of primary diseases is very different in the prevalent population compared to findings in the incident patients. Primary glomerulonephritis, at fourth place among incident patients, is the most frequent disease in the prevalent population (although there is a clearly downward trend over the years). The percentages of diabetes and vascular disease, on the other hand, are lower compared to what is observed in the incident population. The prevalence expressed by treatment modality pmp increased for all three types. In analyzing the annual percentage rise in prevalence, using 1998 as the baseline, the most significant figure regards transplant patients, whose prevalence increased by over 60% between 1998 and 2007. Prevalence of hemodialysis patients rose moderately by only slightly over 10%. Peritoneal dialysis shows a rather linear increase, similar to the transplant trend. Our study used longitudinal regression models to analyze factors predictive of a patient starting and continuing to undergo the same type of treatment over the years. The results show that a patient has a greater probability of being treated with hemodialysis based on several primary nephropathies, when aged > 45, and in the presence of the main comorbidities. The predictive factors for peritoneal dialysis mentioned earlier have a diametrically opposed role. The presence of comorbidities (except high blood pressure), the type of nephropathy, and age > 65 lead to a lower probability of receiving a transplant. We analyzed peritoneal dialysis failures - defined as changing over to extracorporeal dialysis for any reason (clinical, psychological or social) - and the cumulative incidence of failure, taking into account the two competing outcomes of transplant and death. The only variable associated with peritoneal dialysis failure was the presence of infections. Older patients, patients with peripheral vascular disease, and those with neoplasia are less frequently taken off peritoneal dialysis to receive a transplant, an event occurring more frequently, however, in patients with hypertension. Death is dependent on age, on the presence of peripheral vascular disease and is less frequent in hypertensives. As is the case for peritoneal dialysis, the natural history of kidney transplant can have two competing outcomes: return to dialysis and death. The risk factors associated with return to dialysis are the presence of peripheral vascular disease, hypertension and infections; risk factors associated with death include age, the presence of cerebral vascular disease and neoplasia. From 1998 to 2007, the prevalence of hepatitis C virus-antibody-positive patients decreased by almost one third. The number of antigen-positive hepatitis B patients is declining slowly, but the levels remain in any case very low. The association between the two infections is disappearing: already at very low levels in 1998, that figure was halved by 2007. MORTALITY AND SURVIVAL: The mortality of uremic patients on renal replacement therapy was calculated both as a cumulative incidence, expressed as the number of deaths over patients at risk (alive at the beginning of the study year) and as a mortality rate, expressed as the number of deaths per patients/year. The figure was constant over the years, at around 10%. The mortality of males was no different from that of females; this finding differs from what is observed in the general population where male mortality is markedly higher than that of females. The mortality rate is dependent on the age group of the patient at start of treatment and shows an upward trend that is growing exponentially. The mortality rate in hemodialysis patients remained stable at 15% between 2000 and 2007, while the mortality rate in peritoneal dialysis patients gradually decreased down to 13%. The mortality rate for transplant patients was low and constant, at under 2%. The trend for the various causes of death is stable over the years and shows that the main cause of death is cardiac, accounting for between 30% and 35%, while mortality due to vascular, neoplastic, infection or cachexia-related causes are all roughly at the same rate, between 10% and 15%. (ABSTRACT TRUNCATED)

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