Peritoneal dialysis.

Peritoneal dialysis has now become an established form of renal replacement therapy; nearly half the patients on dialysis in the UK are treated in this way. Survival of patients is now equal to that with haemodialysis. However, long-term peritoneal dialysis (>8 years) is limited to a small percentage of patients because of dropout to haemodialysis for inherent complications of peritoneal dialysis--peritonitis, peritoneal access, inadequate dialysis, and patient-related factors. However, improvements in the understanding of the pathophysiological processes involving the peritoneal membrane have paved the way for advances in the delivery of adequate dialysis, more biocompatible dialysis fluids, and automated peritoneal dialysis. Other technical advances have led to a reduction in peritonitis. Peritoneal dialysis is an important dialysis modality and should be used as an integral part of RRT programmes.

Haemodialysis.

This paper charts the development of haemodialysis, the cornerstone of renal replacement therapy (RRT). It has enabled patients with end-stage renal failure to survive for years, in many cases with a surprisingly good quality of life. Through technological advances, RRT can be offered to patients who are older and more frail. Many have intercurrent comorbid illness. Such patients can have good quality of life, but their survival is shorter since they are likely to succumb early to comorbid illnesses. The challenge to nephrologists is to provide treatment based on exacting standards for all those patients who can benefit, yet to maintain cost-effectiveness. There is increasing recognition that, however good the technology underpinning dialysis, what justifies the cost and commitment that dialysis entails is the provision for the patient of a satisfactory quality of life.

Renal impairment in myeloma: time for a reappraisal?

It is generally considered that a patient with myeloma who also has established renal impairment is unlikely to do well. While this is sometimes the case, analysis of recent data shows: (a) of 2768 patients in the MRC database for the fourth to the sixth trials, 10/163 with serum creatinine 300-600 microm/l and 20/89 with serum creatinine 600 micro/l at presentation had renal failure as a recorded presenting feature, whatever the renal function, the most common presenting feature was bone pain; (b) that many patients have persisting evidence of reduced renal function yet survive for more than the median time of 36 months which applies to myeloma generally. Patients with renal impairment, especially those whose myeloma is brought to plateau by chemotherapy, should be assessed thoroughly for evidence of other than myeloma induced renal damage as both renovascular disease and prostatic obstruction in males are common in the elderly population at risk.

Cost of renal replacement therapy.

Renal replacement therapy (RRT) now sustains an older, medically complicated population, reducing dependency on haemodialysis. Costing focuses on avoidable treatment costs, e.g. late referral for management and inappropriate placement on a RRT modality because of restricted local options. Sound regional plans need to be implemented so that patients can be appropriately treated.

Comparison between two prospective studies of cardiovascular disease carried out amongst renal replacement patients in UK and Italy.

The data on 256 non-diabetic patients entering renal replacement therapy (RRT) in Manchester between 1 January 1983 and 31 December 1986 were compared with those on 84 non-diabetic patients entering RRT in Milan between 1 January 1983 and 31 December 1988. In each unit, patients had been studied prospectively and the findings were entered on the same database for this report. At the end of the study, 68% of patients were alive in each centre and in each 16% had died from cardiovascular disease. 11% of Manchester and 18% of the Milan patients developed angina. The data do not support the view that there is a differential risk for cardiovascular disease in the Northern and Southern parts of Europe and it may be advisable to study the matter prospectively in a larger patient cohort.

Long-term outcome of adult-onset minimal-change nephropathy.

BACKGROUND: Adult-onset minimal-change nephropathy has been associated with a slower response to corticosteroids and a less benign prognosis when compared to children. However, there are few long-term outcome data reported. METHODS: We have reviewed retrospectively 51 idiopathic adult-onset minimal-change nephropathy patients investigated and treated at a single centre. RESULTS: Male to female ratio was 1:1.4, mean age at diagnosis was 37 years, and average length of follow-up was 14.1 years. Significant comorbidity was identified in 33%. A raised serum creatinine was found in 55% but returned to normal almost invariably upon remission. At presentation, hypertension was found in 47% of patients, microscopic haematuria in 33%, hypercholesterolaemia and hypertriglyceridaemia in 96%, and hyperuricaemia in 42%. Remission (complete or partial) was achieved by 46, 70 and 92% within 4, 8 and 21 weeks respectively, in patients treated with steroids; steroid resistance was encountered in 8%. The time to remission was positively correlated with age (P = 0.002) and initial albumin level (P = 0.005), and negatively correlated to the number of subsequent relapses (P = 0.029); 33% of patients had a spontaneous remission at some time during the disease course. Patients with multiple relapses were treated with cyclophosphamide and 63% of them had remained in remission after 5 years. Hypertension was present in 25% of patients after an average interval of 11 years. At the time of the final follow-up, only three patients had a raised creatinine and all but three patients were in complete remission. CONCLUSIONS: Adult-onset minimal-change nephropathy shares the same good long-term outcome as the childhood counterpart, with sustained remission and preserved renal function.

Twenty-one years survival with systemic AL-amyloidosis.

AL-amyloidosis has a poor prognosis, typically with cardiac or renal failure ensuing some months after diagnosis. However, sporadically there have been reports of long-term survivors, either with unusual manifestations of amyloidosis, or after concerted chemotherapy to suppress the overt or occult pathological monoclonal plasma cell population responsible for the elaboration of immunoglobulin light chains. We report the case of a 46-year-old man who has survived 21 years after the histological diagnosis of renal amyloidosis was made, after he had presented with severe nephrotic syndrome. This patient was given intensive chemotherapy but came to end-stage renal failure some 10 years later, was dialysed for 1 year, and then was the successful recipient of a cadaveric renal transplant, which is working excellently some 10 years later, with little evidence of recurrent renal or systemic amyloidosis. There is renewed interest in therapy for systemic amyloidosis, and this case demonstrates that with this approach the prognosis can be more favorable than is commonly assumed.

Repeated successful pregnancies after kidney transplantation in 102 women (Report by the EDTA Registry).

BACKGROUND: Between 1967 and 1990, 820 successful pregnancies in 718 women on renal replacement therapy (RRT) were reported to the EDTA Registry. METHODS: This study analyses data on repeated successful pregnancies in 102 of these women, of whom 99 had two and three had three pregnancies. RESULTS: Primary renal diseases were mainly glomerulonephritis (41%), pyelonephritis (32%), and congenital malformations such as cystic diseases and hypoplasia or dysplasia (3%). Mean age at start of RRT was 21 years +/-5 SD. Ninety-four per cent of the women had the same transplant during the first and second pregnancies; 85% of these were alive with their first graft and 9% with a second graft; 4% were retransplanted after the first pregnancy and 2% were back on dialysis during the second pregnancy. Of the mothers with two successful pregnancies, two-thirds had a serum creatinine below 121 micromol/l after the first or after the second pregnancy. Six mothers lost their first graft after the first pregnancy. None of the mothers had died after delivery of the second or third baby. Several features of the first and the second pregnancy in these mothers were quite similar. Mean gestational age was 36 weeks+/-3SD during first and second pregnancy. Mean birth weight (height) of the first child was 2490 g+/-660 SD (48 cm+/-4 SD) and 2587 g+/-639 SD (50 cm+/-3 SD) of the second child (NS). Neonatal mortality was 4% after the first and second delivery; congenital abnormalities were found in five and three children respectively. CONCLUSIONS: Fourteen per cent of mothers who had a successful pregnancy on RRT subsequently had a second baby. Repeated pregnancies should not adversely affect graft function and/or fetal development provided that graft function was well preserved at the time of conception.

The need and demand for renal replacement therapy in ethnic minorities in England.

STUDY OBJECTIVE: The study aimed to determine the relative risk of being accepted for renal replacement treatment of black and Asian populations compared with whites in relation to age, sex, and underlying cause. The implications for population need for renal replacement therapy in these populations and for the development of renal services were also considered. DESIGN/SETTING: This was a cross sectional retrospective survey of all patients accepted for renal replacement treatment in renal units in England in 1991 and 1992. PATIENTS: These comprised all 5901 patients resident in England with end-stage renal failure who had been accepted for renal replacement therapy in renal units in England and whose ethnic category was available from the units. Patients were categorised as white, Asian, black, or other. Population denominators for the ethnic populations were taken from the 1991 census. The census categories Indian, Pakistani, and Bangladeshi were aggregated to form the denominator for Asian patients, and black Caribbeans, black Africans, and black others were aggregated to form the denominator for black patients. MAIN RESULT: Altogether 7.7% of patients accepted were Asian and 4.7% were black; crude relative acceptance rates compared with whites were 3.5 and 3.2 respectively. Age sex specific relative acceptance ratios increased with age in both ethnic populations and were greater in females. Age standardised acceptance ratios were increased 4.2 and 3.7 times in Asian and black people respectively. The most common underlaying cause in both these populations was diabetes; relative rates of acceptance for diabetic end-stage renal failure were 5.8 and 6.5 respectively. The European Dialysis and Transplant Association coding system was inaccurate for disaggregating non-insulin and insulin dependent forms. "Unknown causes" were an important category in Asians with a relative acceptance of rate 5.7. The relative rates were reduced only slightly when the comparison was confined to the district health authorities with large ethnic minority populations, suggesting that geographical access was not a major factor in the high rates for ethnic minorities. CONCLUSION: Acceptance rates for renal replacement treatment are increased significantly in Asian and black populations. Although data inaccuracies and access factors may contribute to these findings, the main reason is probably the higher incidence of end-stage renal failure. This in turn is due to the greater prevalence of underlying diseases such as non-insulin dependent diabetes but possibly also increased susceptibility of developing nethropathy. The main implication is that these populations age demand for renal replacement treatment will increase. This will have an impact nationally but will be particularly apparent in areas with large ethnic minority populations. Future planning must take these factors into account and should include strategies for preventing chronic renal failure, especially that due to non-insulin dependent diabetes and hypertension. The data could not determine the extent to which population need was being met; further studies are required to estimate the incidence of end-stage renal failure in ethnic minority populations.

The need and demand for renal replacement therapy in ethnic minorities in England

STUDY OBJECTIVE: The study aimed to determine the relative risk of being accepted for renal replacement treatment of black and Asian populations compared with whites in relation to age, sex and underlying cause. The implications for population need for renal replacement therapy in these populations and for the development of renal services were also considered. DESIGN/SETTING: This was a cross sectional retrospective survey of all patients accept for renal replacement treatment in renal units in England in 1991 and 1992. PATIENTS: These comprised all 5901 patients resident in England with end-stage renal failure who had been accepted for renal replacement therapy in renal units in England and whose ethnic category was available form the units. Patients were catergorised as white, Asian, black, or other. Population denominators for the ethnic populations were taken from the 1991 census. The census categories Indian, Pakistani, and Bangladeshi were aggregated to form the denominator for Asian patients and black Caribbeans, black Africans, and black others were aggregated to form the denominator for black patients. MAIN RESULT: Altogether 7.7 percent of patients accepted were Asian and 4.7 percent were black; crude relative acceptance rates compared with whites were 3.5 and 3.2 respectively. Age sex specific relative acceptance ratios increased with age in both ethnic populations and were greater in females. Age standardised acceptance ratios were increased 4.2 and 3.7 times in Asian and black people respectively. The most common underlying cause in both these populations was diabetes; relative rates of acceptance for diabetic end-stage renal failure were 5.8 and 6.5 respectively. The European Dialysis and Transplant Association coding system was inaccurate for disaggregating non-insulin and insulin dependent forms. Unknown causes were an important category in Asians with a relative acceptance of rate 5.7. The relative rates were reduced only slightly when the comparison was confined to the district health authorities with large ethnic minority populations, suggesting that geographical access was not a major factor in the high rates for ethnic minorities. CONCLUSION: Acceptance rates for renal replacement treatment are increased significantly in Asian and black populations. Although data inaccuracies and access factors may contributed to these findings, the main reason is probably the higher incidence of end-stage renal failure.(AU)

Complete clinical remission and subsequent relapse of bronchiectasis-related (AA) amyloid induced nephrotic syndrome.

Systemic amyloidosis normally has a dismal prognosis. However, there are several case reports of protracted survival, usually as a response to measures designed to retard the further deposition of amyloid fibrils. In AA amyloid, most commonly associated with inflammatory rheumatological, bowel, and chest diseases, such interventions have had some success, but the dramatic response of complete resolution of nephrotic syndrome as a result of the regular institution of postural chest drainage and antibiotic therapy, in the clinical context of bronchiectasis, has been previously reported only once. In both of our cases, after protracted remission, such therapy was abandoned by the patients, leading both to recurrence of nephrotic syndrome and also eventually to end-stage renal failure requiring dialysis.

Transplantation in the elderly.

Studies show that at present fewer patients aged > 60 are on the waiting list for transplantation than would be predicted from their proportion on renal replacement therapy by dialysis. Evidence to date shows that in these older subjects loss of grafts by rejection is less common than it is in younger subjects; there is also absolutely a greater loss of grafts due to death of the patient while the graft still functions. Well-matched grafts should be available to older subjects in whom thorough clinical assessment makes unlikely early death, particularly from cardiovascular causes, following transplantation. If this is to be achieved, agreed approaches to the assessment of such patients and to their inclusion on transplant waiting lists must be established.

Urinary C5b-9 excretion and clinical course in idiopathic human membranous nephropathy.

Recent reports suggested that the presence of terminal complement complex (C5b-9) in urine from patients with idiopathic membranous nephropathy (IMN) may indicate on-going immunological damage. This report documents the relationship between C5b-9 excretion and clinical outcome in 35 adult patients with biopsy-proven IMN and progressively declining renal function. There were two groups of patients. Group I received one of three treatment regimens: prednisolone alone, prednisolone and chlorambucil, or prednisolone and cyclophosphamide (N = 22). Group II received no immunosuppressive therapy (N = 17). Three of the 18 patients receiving immunosuppressive drugs had more than one treatment regimen as they experienced a clinical relapse during the study period; hence 22 treatments were available for analysis. Urine samples were collected regularly and urinary C5b-9 (uC5b-9) was determined by ELISA. Both groups were similar with respect to age, sex distribution, and the duration of follow-up. An improvement in proteinuria and creatinine clearance was noted in the immunosuppressed group. Thirty-five patients were excreting C5b-9 initially (18 from group I and 17 from group II); 17 patients continued to excrete C5b-9 at the end of the observation period. These 17 patients had a significantly worse clinical outcome when compared to the 18 patients whose C5b-9 excretion became negative, either spontaneously or with treatment (P < 0.005). These results indicate that continuing C5b-9 excretion is correlated with a poor clinical outcome. They also suggest that uC5b-9 is a dynamic marker of ongoing immunological injury, and therefore may be useful in the initial assessment and monitoring of patients with IMN and in identifying patients who may derive benefit from immunosuppressive therapy.

The European (European Dialysis and Transplantation Association-European Renal Association) Registry.

The European Dialysis and Transplantation Association-European Renal Association (EDTA-ERA) Registry, now some 30 years old, has collected data throughout Europe since its inception and now covers nearly 700 million people in some 36 countries. Approximately 2,000 centers report to it. It has been possible to follow the way in which treatment for renal failure has developed in Europe, and this has not always been uniform. The nature of the treatment offered, the survival of patients on treatment, and sequentially many areas of their management have been addressed and reported. The Registry continues to work both in the field of end-stage renal failure and other fields of renal disease. It is assisting in the development of national registries and subnational renal registries throughout Europe. The multinational, multicultural nature of its area of interests makes this Registry a uniquely placed source to study many aspects of the management of patients with renal disease and of contributing to their care in the variety of healthcare system that exist in Europe and in the countries bordering the Mediterranean.