Measures of care in adult renal transplant recipients in the United Kingdom (chapter 11).

The total number of patients active on the transplant waiting list (adult and paediatric) on 31 December 2005 was 5736, an 8% increase from the previous year. On 31 December 2005, 45.7% of prevalent adult RRT patients in the UK, had a functioning renal transplant which equated to 19,074 patients. During 2005, the death rate in prevalent transplant patients was 2.7 per 100 patient years. An additional 3.1% of all prevalent transplants failed with patients returning to dialysis. During 2005, deceased heart beating donor numbers decreased by 18% compared to 2004. In comparison, non-heart beating donors and living kidney donors increased by 35% and 17%, respectively, in 2005. The proportion of renal transplants performed from deceased heart beating donors fell from 68% in 2004 to 60% in 2005. There is wide variation in prevalence per million population (pmp) of transplanted patients resident in each local authority area across the United Kingdom. Total 11.4% of incident transplants in 2005 were due to patients with diabetes. The median eGFR was 46.1 ml/min/1.73 m(2), with 18% of prevalent transplant recipients having an eGFR <30 ml/min/1.73 m(2). The median Hb in prevalent transplant recipients was 12.9 g/dl, with 10% of patients having an Hb <10 g/dl. The median systolic and diastolic BP was 136 and 79 mmHg, respectively, with only 25% of patients within guidelines. Transplant function analysed by CKD stages 1-2 (eGFR < 60), 3 (eGFR 30-59), 4 (eGFR 15-29) and 5 (eGFR < 15), shows that these categories account for 24%, 59%, 15% and 2.5% of patients, respectively. Haemoglobin values fall with decreasing eGFR such that of the 2.5% of transplant patients with eGFR <15 ml/min, 27% had an Hb <10 g/dl and 51% <11 g/dl. Control of iPTH was poor in transplant recipients in CKD stages 4 and 5, with 22% and 50% of patients, respectively, having a PTH > 32 pmol/l (=300 ng/l). Patients with failing transplants are less likely to achieve RA targets of key biochemical variables when compared to patients on dialysis. There is still wide variability in the completeness of data returns from individual units.

Survival of incident RRT patients in the UK (chapter 12).

This analysis presents the survival of patients starting renal replacement therapy (RRT) in UK renal units ('centres'), and includes an analysis of survival by centre. Data from 59 of the 70 UK centres are included. This is the first year that UK centre anonymity has been removed from analysis of patient survival by centre. Survival after adjustment for comorbidity is also reported for the first time although this analysis is restricted to those centres returning data on comorbidity in at least 85% of incident patients. The importance of adjusting for comorbidity can be seen in that for one centre, after adjustment of survival for age and diagnosis, the adjusted 1 year after 90 day survival was 84.6%. After adjusting to the average comorbidity present across centres, survival increased to 90.4%. Improved comorbidity data returns by renal units may require investment in informatics staff and creating structural process at renal unit level for clinicians to support these data returns. From the date of first RRT, the 1 year survival of all patients (unadjusted for age) is 79%. From the 90th day of RRT (to allow comparison with other countries' 1 year survival), the 1 year survival is 83%. The age adjusted (60 years) survival for the 1 year after 90 day period is 86%. There is a high death rate in the first 90 days on RRT (6% of all patients starting RRT), a period not included in reports by many registries and other studies. The 5 year survival (including deaths within the first 90 days) rates are 58, 53, 44, 28, 19 and 12%, respectively for patients aged 18-34, 35-44, 45-54, 55-64, 65-74 and >75 years. The 'vintage effect' of increasing hazard of death with length of time on RRT, prominent in data from the US, is only noted in older age groups (65-75 and 75+ years) at 5-6 years after starting RRT. Six centres had a figure for the 1 year after 90 day survival which was outside 2 SDs from the mean for the UK: in three cases this was better survival, and in three, poorer survival, than expected. Poor reporting by renal units of patient comorbidity makes interpretation of these apparent differences in patient survival between centres difficult and a relationship to clinical performance cannot yet be inferred.

Comorbidities in UK patients at the start of renal replacement therapy (chapter 6).

Comorbidity returns have continued to improve, albeit slowly, with centres running Mediqal software having the highest rates of completeness. Diabetes as a primary renal diagnosis accounted for 20% of those starting RRT, but a further 7% had diabetes present as a comorbid condition. The incidence of smoking remained high at 17% of diabetic patients, which was similar to that found in non-diabetics. Twelve percent of the patients starting RRT had a previous myocardial infarction (MI) and 31% of those aged over 65 years starting RRT had ischaemic heart disease (IHD). Patients starting on peritoneal dialysis (PD) were on average 9 years younger than those on haemodialysis (HD) and had fewer comorbidities present. Patients starting RRT without any comorbidity present had a lower median estimated glomerular filtration rate (eGFR) than those with comorbid conditions. Patients with a previous MI or coronary artery bypass grafting (CABG), started RRT with slightly higher mean haemoglobin than those without comorbid conditions or other comorbid conditions. On univariate survival analysis, diabetes was not associated with an increased risk of death amongst patients aged over 65 years, possibly due to its close association with other comorbidities in this age group. In the multivariate survival analysis, the presence of ischaemic/neuropathic ulcers was the predictor of worst survival, followed by malignancy, previous MI and age per 10 year increment. Smoking was less common in both South Asian and black patients than whites (7 vs 17%) starting RRT. Twenty-three percent of both South Asian and white patients started RRT with IHD compared with only 12% of Black patients.