Publications by authors named "Retha Steenkamp"

51 Publications

Contributions of treatment centre and patient characteristics to patient-reported experience of haemodialysis: a national cross-sectional study.

BMJ Open 2021 04 14;11(4):e044984. Epub 2021 Apr 14.

Life and Medical Sciences, University of Hertfordshire, Hatfield, UK.

Objectives: To examine the relative importance of patient and centre level factors in determining self-reported experience of care in patients with advanced kidney disease treated by maintenance haemodialysis (HD).

Design: Analysis of data from a cross sectional national survey; the UK Renal Registry (UKRR) national Kidney patient-reported experience measure (PREM) survey (2018). Centre-level data were obtained from the UKRR report (2018).

Setting: National survey of patients with advanced kidney disease receiving treatment with maintenance HD in UK renal centres in 2018.

Participants: The Kidney PREM was distributed to all UK renal centres by the UKRR in May 2018. Each centre invited patients receiving outpatient treatment for kidney disease to complete the PREM. These included patients with chronic kidney disease, those receiving dialysis-both HD and peritoneal dialysis, and those with a functioning kidney transplant. There were no formal inclusion/exclusion criteria.

Main Outcome Measures: The Kidney PREM has 38 questions in 13 subscales. Responses were captured using a 7-point Likert scale ( 1, 7). The primary outcome of interest was the mean PREM score calculated across all questions. Multilevel modelling was used to determine the proportion of variation of the mean PREM score across centres due to patient-related and centre-related factors.

Results: There were records for 8253 HD patients (61% men, 77% white) from 69 renal centres (9-710 patients per centre). There was significant variation in mean PREM score across centres (5.35-6.53). In the multivariable analysis there was some variation in relation to both patient- and centre-level factors but these contributed little to explaining the overall variation. However, multilevel modelling showed that the overwhelming proportion of the explained variance (45%) was explained by variation between centres (40%), only a small proportion of which is identified by measured factors. Only 5% of the variation was related to patient-level factors.

Conclusions: Centre rather than patient characteristics determine the experience of care of patients receiving HD. Further work is required to define the characteristics of the treating centre which determine patient experience.
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http://dx.doi.org/10.1136/bmjopen-2020-044984DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8054084PMC
April 2021

Do routine hospital data accurately record comorbidity in advanced kidney disease populations? A record linkage cohort study.

BMC Nephrol 2021 03 17;22(1):95. Epub 2021 Mar 17.

Richard Bright Renal Service, Southmead Hospital, Bristol, BS10 5NB, UK.

Background: Routine healthcare datasets capturing clinical and administrative information are increasingly being used to examine health outcomes. The accuracy of such data is not clearly defined. We examine the accuracy of diagnosis recording in individuals with advanced chronic kidney disease using a routine healthcare dataset in England with comparison to information collected by trained research nurses.

Methods: We linked records from the Access to Transplant and Transplant Outcome Measures study to the Hospital Episode Statistics dataset. International Classification of Diseases (ICD-10) and Office for Population Censuses and Surveys Classification of Interventions and Procedures (OPCS-4) codes were used to identify medical conditions from hospital data. The sensitivity, specificity, positive and negative predictive values were calculated for a range of diagnoses.

Results: Comorbidity information was available in 96% of individuals prior to starting kidney replacement therapy. There was variation in the accuracy of individual medical conditions identified from the routine healthcare dataset. Sensitivity and positive predictive values ranged from 97.7 and 90.4% for diabetes and 82.6 and 82.9% for ischaemic heart disease to 44.2 and 28.4% for liver disease.

Conclusions: Routine healthcare datasets accurately capture certain conditions in an advanced chronic kidney disease population. They have potential for use within clinical and epidemiological research studies but are unlikely to be sufficient as a single resource for identifying a full spectrum of comorbidities.
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http://dx.doi.org/10.1186/s12882-021-02301-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7968235PMC
March 2021

Survival of South African patients on renal replacement therapy.

Clin Kidney J 2020 Oct 4;13(5):782-790. Epub 2020 Mar 4.

Division of Nephrology, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa.

Background: The majority of South Africans rely on a resource-constrained public healthcare sector, where access to renal replacement therapy (RRT) is strictly rationed. The incidence of RRT in this sector is only 4.4 per million population (pmp), whereas it is 139 pmp in the private sector, which serves mainly the 16% of South Africans who have medical insurance. Data on the outcomes of RRT may influence policies and resource allocation. This study evaluated, for the first time, the survival of South African patients starting RRT based on data from the South African Renal Registry.

Methods: The cohort included patients with end-stage kidney disease who initiated RRT between January 2013 and September 2016. Data were collected on potential risk factors for mortality. Failure events included stopping treatment without recovery of renal function and death. Patients were censored at 1 year or upon recovery of renal function or loss to follow-up. The 1-year patient survival was estimated using the Kaplan-Meier method and the association of potential risk factors with survival was assessed using multivariable Cox proportional hazards regression.

Results: The cohort comprised 6187 patients. The median age was 52.5 years, 47.2% had diabetes, 10.2% were human immunodeficiency virus (HIV) positive and 82.2% had haemodialysis as their first RRT modality. A total of 542 patients died within 1 year of initiating RRT, and overall 1-year survival was 90.4% [95% confidence interval (CI) 89.6-91.2]. Survival was similar in patients treated in the private sector as compared with the public healthcare sector [hazard ratio 0.93 (95% CI 0.72-1.21)]. Higher mortality was associated with older age and a primary renal diagnosis of 'Other' or 'Aetiology unknown'. When compared with those residing in the Western Cape, patients residing in the Northern Cape, Eastern Cape, Mpumalanga and Free State provinces had higher mortality. There was no difference in mortality based on ethnicity, diabetes or treatment modality. The 1-year survival was 95.9 and 94.2% in HIV-positive and -negative patients, respectively. One-fifth of the cohort had no data on HIV status and the survival in this group was considerably lower at 77.1% (P < 0.001).

Conclusions: The survival rates of South African patients accessing RRT are comparable to those in better-resourced countries. It is still unclear what effect, if any, HIV infection has on survival.
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http://dx.doi.org/10.1093/ckj/sfaa012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7577754PMC
October 2020

Sociodemographic features and mortality of individuals on haemodialysis treatment who test positive for SARS-CoV-2: A UK Renal Registry data analysis.

PLoS One 2020 23;15(10):e0241263. Epub 2020 Oct 23.

UK Renal Registry, The Renal Association, Bristol, United Kingdom.

Kidney disease is a recognised risk factor for poor COVID-19 outcomes. Up to 30 June 2020, the UK Renal Registry (UKRR) collected data for 2,385 in-centre haemodialysis (ICHD) patients with COVID-19 in England and Wales. Overall unadjusted survival at 1 week after date of positive COVID-19 test was 87.5% (95% CI 86.1-88.8%); mortality increased with age, treatment vintage and there was borderline evidence of Asian ethnicity (HR 1.16, 95% CI 0.94-1.44) being associated with higher mortality. Compared to the general population, the relative risk of mortality for ICHD patients with COVID-19 was 45.4 and highest in younger adults. This retrospective cohort study based on UKRR data supports efforts to protect this vulnerable patient group.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0241263PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7584244PMC
November 2020

Data from the ERA-EDTA Registry were examined for trends in excess mortality in European adults on kidney replacement therapy.

Kidney Int 2020 10 20;98(4):999-1008. Epub 2020 Jun 20.

ERA-EDTA Registry, Department of Medical Informatics, Amsterdam UMC, Academic Medical Center, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, the Netherlands.

The objective of this study was to investigate whether the improvement in survival seen in patients on kidney replacement therapy reflects the enhanced survival of the general population. Patient and general population statistics were obtained from the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry and the World Health Organization databases, respectively. Relative survival models were composed to examine trends over time in all-cause and cause-specific excess mortality, stratified by age and modality of kidney replacement therapy, and adjusted for sex, primary kidney disease and country. In total, 280,075 adult patients started kidney replacement therapy between 2002 and 2015. The excess mortality risk in these patients decreased by 16% per five years (relative excess mortality risk (RER) 0.84; 95% confidence interval 0.83-0.84). This reflected a 14% risk reduction in dialysis patients (RER 0.86; 0.85-0.86), and a 16% increase in kidney transplant recipients (RER 1.16; 1.07-1.26). Patients on dialysis showed a decrease in excess mortality risk of 28% per five years for atheromatous cardiovascular disease as the cause of death (RER 0.72; 0.70-0.74), 10% for non-atheromatous cardiovascular disease (RER 0.90; 0.88-0.92) and 10% for infections (RER 0.90; 0.87-0.92). Kidney transplant recipients showed stable excess mortality risks for most causes of death, although it did worsen in some subgroups. Thus, the increase in survival in patients on kidney replacement therapy is not only due to enhanced survival in the general population, but also due to improved survival in the patient population, primarily in dialysis patients.
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http://dx.doi.org/10.1016/j.kint.2020.05.039DOI Listing
October 2020

Randomized Trial Comparing Proactive, High-Dose versus Reactive, Low-Dose Intravenous Iron Supplementation in Hemodialysis (PIVOTAL): Study Design and Baseline Data.

Am J Nephrol 2018 10;48(4):260-268. Epub 2018 Oct 10.

Robertson Centre for Biostatistics, University of Glasgow, Glasgow, United Kingdom.

Background: Intravenous (IV) iron supplementation is a standard maintenance treatment for hemodialysis (HD) patients, but the optimum dosing regimen is unknown.

Methods: PIVOTAL (Proactive IV irOn Therapy in hemodiALysis patients) is a multicenter, open-label, blinded endpoint, randomized controlled (PROBE) trial. Incident HD adults with a serum ferritin < 400 µg/L and transferrin saturation (TSAT) levels < 30% receiving erythropoiesis-stimulating agents (ESA) were eligible. Enrolled patients were randomized to a proactive, high-dose IV iron arm (iron sucrose 400 mg/month unless ferritin > 700 µg/L and/or TSAT ≥40%) or a reactive, low-dose IV iron arm (iron sucrose administered if ferritin <200 µg/L or TSAT < 20%). We hypothesized that proactive, high-dose IV iron would be noninferior to reactive, low-dose IV iron for the primary outcome of first occurrence of nonfatal myocardial infarction (MI), nonfatal stroke, hospitalization for heart failure or death from any cause. If noninferiority is confirmed with a noninferiority limit of 1.25 for the hazard ratio of the proactive strategy relative to the reactive strategy, a test for superiority will be carried out. Secondary outcomes include infection-related endpoints, ESA dose requirements, and quality-of-life measures. As an event-driven trial, the study will continue until at least 631 primary outcome events have accrued, but the expected duration of follow-up is 2-4 years.

Results: Of the 2,589 patients screened across 50 UK sites, 2,141 (83%) were randomized. At baseline, 65.3% were male, the median age was 65 years, and 79% were white. According to eligibility criteria, all patients were on ESA at screening. Prior stroke and MI were present in 8 and 9% of the cohort, respectively, and 44% of patients had diabetes at baseline. Baseline data for the randomized cohort were generally concordant with recent data from the UK Renal Registry.

Conclusions: PIVOTAL will provide important information about the optimum dosing of IV iron in HD patients representative of usual clinical practice.

Trial Registration: EudraCT number: 2013-002267-25.
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http://dx.doi.org/10.1159/000493551DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6262676PMC
January 2020

Causes of renal allograft failure in the UK: trends in UK Renal Registry and National Health Service Blood and Transplant data from 2000 to 2013.

Nephrol Dial Transplant 2019 02;34(2):355-364

Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK.

Background: Improvement in long-term renal allograft survival is impeded by incomplete or erroneous coding of causes of allograft loss. This study reports 13-year trends in causes of graft failure across the UK.

Methods: National Health Service Blood and Transplant (NHSBT) and UK Renal Registry data were linked to describe UK kidney patients transplanted in 2000-13. NHSBT graft failure categories were used, with 'other' recoded when free text was available. Adjusted analyses examined the influence of age, ethnicity and donor type on causes of graft failure.

Results: In 22 730 recipients, 5389 (23.7%) grafts failed within a median follow-up of 5 years. The two most frequent causes were death with a functioning graft (40.8%) and alloimmune pathology (25.0%). Graft survival was higher in recipients who were younger (mean 47.3 versus 50.7 years), received a pre-emptive transplant (20.2% versus 10.4%), spent less time on dialysis (median 1.6 versus 2.4 years) and received a living donor transplant (36.3% versus 22.2%), with no differences by sex, ethnicity or human leucocyte antigen mismatch. Allograft failure within 2 years of transplantation fell from 12.5% (2000-4) to 9.8% (2009-13). Surgical- and alloimmune-related failures decreased over time while death with a functioning graft became more common. Age, ethnicity and donor type were factors in recurrent primary disease and alloimmune pathology.

Conclusions: Since 2000 there have been reductions in surgical and alloimmune graft failures in the UK. However, graft failure codes need to be revised if they are to remain useful and effective in epidemiological and quality improvement trials.
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http://dx.doi.org/10.1093/ndt/gfy168DOI Listing
February 2019

The UK Renal Registry: making patient data matter.

Br J Hosp Med (Lond) 2018 May;79(5):246-248

Medical Director, UK Renal Registry, Southmead Hospital, Bristol, and Population Health Sciences, University of Bristol, Bristol.

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http://dx.doi.org/10.12968/hmed.2018.79.5.246DOI Listing
May 2018

UK Renal Registry 19th Annual Report: Introduction.

Nephron 2017 29;137 Suppl 1:1-10. Epub 2017 Sep 29.

UK Renal Registry, Bristol, UK.

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http://dx.doi.org/10.1159/000481362DOI Listing
July 2018

Predicting 6-month mortality risk of patients commencing dialysis treatment for end-stage kidney disease.

Nephrol Dial Transplant 2017 Sep;32(9):1558-1565

Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.

Background: There is evidence that end-stage kidney disease patients who are older or with more comorbidity may have a poor trade-off between benefits of dialysis and potential harms. We aimed to develop a tool for predicting patient mortality in the early stages of receiving dialysis.

Methods: In 23 658 patients aged 15+ years commencing dialysis between 2000 and 2009 in Australia and New Zealand a point score tool was developed to predict 6-month mortality based on a logistic regression analysis of factors available at dialysis initiation. Temporal validation used 2009-11 data from Australia and New Zealand. External validation used the UK Renal Registry.

Results: Within 6 months of commencing dialysis 6.1% of patients had died. A small group (4.7%) of patients had a high predicted mortality risk (>20%), as predicted by the point score tool. Predictive variables were: older age, underweight, chronic lung disease, coronary artery disease, peripheral vascular disease, cerebrovascular disease (particularly for patients <60 years of age), late referral to nephrologist care and underlying cause of renal disease. The new point score tool outperformed existing models, and had an area under the receiver operating characteristic curve of 0.755 on temporal validation with acceptable calibration and 0.713 on external validation with poor calibration.

Conclusion: Our point score tool for predicting 6-month mortality in patients at dialysis commencement has sufficient prognostic accuracy to use in Australia and New Zealand for prognosis and identification of high risk patients who may be given appropriate supportive care. Use in other countries requires further study.
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http://dx.doi.org/10.1093/ndt/gfw383DOI Listing
September 2017

Measuring senescence rates of patients with end-stage renal disease while accounting for population heterogeneity: an analysis of data from the ERA-EDTA Registry.

Ann Epidemiol 2016 11 31;26(11):773-779. Epub 2016 Aug 31.

Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, The Netherlands.

Purpose: Although a population's senescence rate is classically measured as the increase in mortality rate with age on a logarithmic scale, it may be more accurately measured as the increase on a linear scale. Patients on dialysis, who suffer from accelerated senescence, exhibit a smaller increase in their mortality rate on a logarithmic scale, but a larger increase on a linear scale than patients with a functioning kidney transplant. However, this comparison may be biased by population heterogeneity.

Methods: Follow-up data on 323,308 patients on dialysis and 91,679 patients with a functioning kidney transplant were derived from the ERA-EDTA Registry. We measured the increases in their mortality rates using Gompertz frailty models that allow individual variation in this increase.

Results: According to these models, the senescence rate measured as the increase in mortality rate on a logarithmic scale was smaller in patients on dialysis, while the senescence rate measured as the increase on a linear scale was larger in patients on dialysis than patients with a functioning kidney transplant.

Conclusions: Also when accounting for population heterogeneity, a population's senescence rate is more accurately measured as the increase in mortality rate on a linear scale than a logarithmic scale.
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http://dx.doi.org/10.1016/j.annepidem.2016.08.010DOI Listing
November 2016

UK Renal Registry 18th Annual Report: Chapter 7 Adequacy of Haemodialysis in UK Adult Patients in 2014: National and Centre-specific Analyses.

Nephron 2016 19;132 Suppl 1:155-68. Epub 2016 Apr 19.

Royal Free Hospital, London, UK.

Data suitable for urea reduction ratio (URR) analyses were available for 14,761 (71.9%) of the 20,539 patients receiving haemodialysis (HD) in the UK on the 30/9/2014. In 2014, 88.6% of prevalent HD patients achieved a URR .65%. The between centre range of prevalent patients achieving this target was wide (74.9-97.0%). The median URR in 2014 was 75%. URR was greater in those with longer dialysis vintage, with 91.2% of patients who had survived on renal replacement therapy (RRT) for more than two years achieving a URR .65% compared with only 73.4% of those on RRT for less than six months. Large variation between centres in the percentage of patients achieving the UK Renal Association's (RA) URR guideline persists.
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http://dx.doi.org/10.1159/000444821DOI Listing
January 2017

UK Renal Registry 18th Annual Report: Chapter 6 Comorbidities and Current Smoking Status amongst Patients starting Renal Replacement Therapy in England, Wales and Northern Ireland from 2013 to 2014.

Nephron 2016 19;132 Suppl 1:145-54. Epub 2016 Apr 19.

UK Renal Registry, Bristol, UK.

Data on comorbidity at the time of start of renal replacement therapy (RRT) were submitted to the UK Renal Registry (UKRR) for 7,786 (58.1%) incident patients between 2013 and 2014. In 2014, 11 centres provided data on 100% of new patients and eight provided data for less than 5% of new patients, highlighting the continued wide variation in the completeness of data returns. In 2014, comorbidity data completeness in Wales and Northern Ireland was around 90% compared with 53% in England. In patients with comorbidity data, about half (49.8%) had one or more comorbidities and in the subgroup of patients aged 565 years, this increased to 63.1%. Diabetes mellitus (listed as primary renal disease or comorbidity) and ischaemic heart disease were the most common comorbid conditions, observed in 36% and 20% of patients respectively. Most comorbid conditions were more prevalent in patients aged 565 years, but the prevalence rates for ischaemic heart disease and malignancy were substantially higher than the rest. In 2013–2014, 12.5% of incident RRT patients were recorded as being smokers at initiation of dialysis; this is a decrease from 14% in the previous two years (2011–2012). Amongst incident RRT patients of White origin, the prevalence of having at least one comorbid condition was approximately 14% and 7% higher than in incident patients of Black and South Asian origin, respectively. There was a higher prevalence of ischaemic heart disease and peripheral vascular disease in patients referred early to a nephrologist than amongst patients referred late. Malignancy was much more common in patients who were referred late.
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http://dx.doi.org/10.1159/000444820DOI Listing
January 2017

UK Renal Registry 18th Annual Report (December 2015) Chapter 5: Survival and Causes of Death in UK Adult Patients on Renal Replacement Therapy in 2014: National and Centre-specific Analyses.

Nephron 2016 19;132 Suppl 1:111-44. Epub 2016 Apr 19.

UK Renal Registry, Bristol, UK.

Survival of incident patients on RRT continued to improve over the last 14 years for both short and long term survival up to 10 years post RRT start. One year after 90 day age adjusted survival for incident RRT patients in the 2013 cohort increased to 91.4% from the previous year (91.0%); survival increased in incident patients aged ,65 years and in older patients (565 years). There was a difference in one year after 90 day incident survival by age group and diabetic status: diabetic patients aged ,65 years have slightly worse survival than non-diabetic patients, but survival for older diabetic patients (565 years) was significantly better than for non-diabetic patients. One year age adjusted survival for prevalent dialysis patients was 88.6% in the 2013 cohort, a slight decrease from the 2012 cohort (89.3%). Age adjusted one year survival for prevalent dialysis patients with diabetic primary renal disease has been declining slightly since 2012. Centre and UK country variability was evident in incident and prevalent patient survival after adjusting to age 60 and this finding would benefit from further investigation. The relative one year risk of death on RRT decreased with age from about 19 times that of the general population at age 35–39 years to 2.6 times at age 85 and over. In the prevalent RRT population, cardiovascular disease was the most common cause of death, accounting for 23% of deaths. Infection accounted for 20% of deaths and treatment withdrawal for 16% of deaths.
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http://dx.doi.org/10.1159/000444819DOI Listing
January 2017

UK Renal Registry 17th Annual Report: Chapter 6 Adequacy of Haemodialysis in UK Adult Patients in 2013: National and Centre-specific Analyses.

Nephron 2015 22;129 Suppl 1:131-42. Epub 2015 Jan 22.

UK Renal Registry, Bristol, UK.

Background: Outcomes in patients treated with haemodialysis(HD) are potentially influenced by the delivered dose of dialysis. The UK Renal Association publishes clinical practice guidelines recommendations for dialysis dose. The urea reduction ratio (URR) is a widely used measure of dialysis dose and has been historically the measure of adequacy reported by the UKRR.

Aim: To determine the extent to which patients achieved the recommended UK target.

Methods: Two groups of patients were included in the analyses: the prevalent HD patients on 30th September 2013 and the incident HD patients for 2012. Centres returning data on ,50% of their patient population or centres with,20 patients with data were excluded from centre-specific comparisons.

Results: Data regarding URR were available for analysis from 64 renal centres in the UK. The proportion of patients in the UK who met the UK clinical practice guideline for URR (.65%) increased from 69% in 2000 to 89% in 2013. There was persistent variation observed between centres, with 22 centres attaining the RA clinical practice guideline in .90% of patients and 37 centres attaining the guideline in 70–90% of patients. The overall proportion of prevalent HD patients with a URR .65% has continued to improve over time.

Conclusions: The delivered dose of HD,as measured by URR for patients with established renal failure,has increased over the last decade. Whilst the majority of UK patients achieved the target URR, there was wide variation between centres in the percentage of patients achieving the current guideline target.
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http://dx.doi.org/10.1159/000370276DOI Listing
January 2016

UK Renal Registry 17th Annual Report: Chapter 5 Survival and Cause of Death in UK Adult Patients on Renal Replacement Therapy in 2013: National and Centre-specific Analyses.

Nephron 2015 22;129 Suppl 1:99-129. Epub 2015 Jan 22.

UK Renal Registry, Bristol, UK.

Introduction: The analyses presented in this chapter examine (a) survival from the start of RRT of adult RRT patients; (b) projected life years remaining for adult patients starting RRT; (c) survival amongst prevalent adult dialysis patients alive on 31st December 2012; (d) the death rate in the UK compared to the general population; (e) cause of death for incident and prevalent adult RRT patients.

Methods: Survival of incident patients was calculated both from the start of RRT and from 90 days after start. One year survival for prevalent dialysis patients were calculated by following patients up for one year in 2013. The relative risk of death was compared with the general UK population.

Results: The age adjusted one year after 90 day survival for patients starting RRT in 2012 was 91.0% (90.9% in 2011). Age adjusted one year survival for prevalent dialysis patients remained relatively unchanged at 89.3% from the previous year. The age-standardised mortality ratio for prevalent RRT patients compared with the general population was 16.2 for age group 35–39 and 2.6 at age 85+ years. In the prevalent RRT dialysis population, cardiovascular disease accounted for 27% of deaths, infection and other causes for 21% each and treatment withdrawal for 16% of deaths.The median life years remaining for a 25–29 year old starting RRT was 18.5 years and approximately 2.4 years for a 75+year old.

Conclusions: Survival of patients starting RRT has improved substantially in last decade, overall, by age and for diabetic patients.
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http://dx.doi.org/10.1159/000370275DOI Listing
January 2016

Inpatient coronary angiography and revascularisation following non-ST-elevation acute coronary syndrome in patients with renal impairment: a cohort study using the Myocardial Ischaemia National Audit Project.

PLoS One 2014 17;9(6):e99925. Epub 2014 Jun 17.

Department of Renal Sciences, Division of Transplantation Immunology and Mucosal Biology, Kings College London, London, United Kingdom.

Background: International guidelines support an early invasive management strategy (including early coronary angiography and revascularisation) for non-ST-elevation acute coronary syndrome (NSTE-ACS) in patients with renal impairment. However, evidence from outside the UK suggests that this approach is underutilised. We aimed to describe practice within the NHS, and to determine whether the severity of renal dysfunction influenced the provision of angiography and modified the association between early revascularisation and survival.

Methods: We performed a cohort study, using multivariable logistic regression and propensity score analyses, of data from the Myocardial Ischaemia National Audit Project for patients presenting with NSTE-ACS to English or Welsh hospitals between 2008 and 2010.

Findings: Of 35 881 patients diagnosed with NSTE-ACS, eGFR of <60 ml/minute/1.73 m(2) was present in 15 680 (43.7%). There was a stepwise decline in the odds of undergoing inpatient angiography with worsening renal dysfunction. Compared with an eGFR>90 ml/minute/1.73 m(2), patients with an eGFR between 45-59 ml/minute/1.73 m(2) were 33% less likely to undergo angiography (adjusted OR 0.67, 95% CI 0.55-0.81); those with an eGFR<30/minute/1.73 m(2) had a 64% reduction in odds of undergoing angiography (adjusted OR 0.36, 95%CI 0.29-0.43). Of 16 646 patients who had inpatient coronary angiography, 58.5% underwent inpatient revascularisation. After adjusting for co-variables, inpatient revascularisation was associated with approximately a 30% reduction in death within 1 year compared with those managed medically after coronary angiography (adjusted OR 0.66, 95%CI 0.57-0.77), with no evidence of modification by renal function (p(interaction) = 0.744).

Interpretation: Early revascularisation may offer a similar survival benefit in patients with and without renal dysfunction, yet renal impairment is an important determinant of the provision of coronary angiography following NSTE-ACS. A randomised controlled trial is needed to evaluate the efficacy of an early invasive approach in patients with severe renal dysfunction to ensure that all patients who may benefit are offered this treatment option.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0099925PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4061061PMC
February 2015

Association between glycemia and mortality in diabetic individuals on renal replacement therapy in the U.K.

Diabetes Care 2014 26;37(5):1304-11. Epub 2014 Feb 26.

Corresponding author: Amanda Adler,

Objective: In the U.K., one-third of patients receiving treatment with dialysis have diabetes. Guidelines from organizations representing patients with renal disease or diabetes advocate tight glycemic control in patients with end-stage renal disease, despite glucose-lowering trials having excluded these patients.

Research Design And Methods: Using national U.K. Renal Registry data, we tested whether glycemia as measured by hemoglobin (Hb) A(1c) (HbA(1c)) level is associated with death in adults with diabetes starting hemodialysis or peritoneal dialysis between 1997 and 2006, and observed for at least 6 months. Of 7,814 patients, we excluded those who had died within 6 months; had received transplants; were lost/recovered; or lacked measures of HbA1c, ethnicity, or Hb. Categorizing HbA1c measured in the first 6 months of starting dialysis as <6.5% (<48 mmol/mol), 6.5-7.4% (48-57 mmol/mol) (reference value), 7.5-8.4% (58-68 mmol/mol), and ≥8.5% (≥69 mmol/mol), we adjusted in proportional hazards models for age, sex, ethnicity, deprivation, year, dialysis type, and Hb, and tested for interactions.

Results: Of 3,157 patients observed for a median time of 2.7 years, 1,688 died. For patients ≥60 years of age, we found no association between HbA1c and death; among younger patients, relative to those with HbA(1c) values 6.5-7.4%, the hazard ratio for HbA(1c) level 7.5-8.4% was 1.2 (95% CI 0.9-1.5), and for HbA(1c) level >8.5% was 1.5 (1.2-1.9). The projected difference in median survival time between younger patients with a reference HbA1c value versus >8.5% was 1 year.

Conclusions: In the absence of trials, and confounding notwithstanding, these observational data support improved glycemic control in younger patients prior to and during dialysis.
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http://dx.doi.org/10.2337/dc13-0553DOI Listing
August 2015

UK Renal Registry 15th annual report: Chapter 5 survival and causes of death of UK adult patients on renal replacement therapy in 2011: national and centre-specific analyses.

Nephron Clin Pract 2013 10;123 Suppl 1:93-123. Epub 2013 Jun 10.

UK Renal Registry, Bristol, UK.

Introduction: These analyses examine a) survival from the start of renal replacement therapy (RRT) based on the total incident UK RRT population reported to the UK Renal Registry, b) survival of prevalent patients. Changes in survival between 1997 and 2011 are also reported.

Methods: Survival was calculated for both incident and prevalent patients on RRT and compared between the UK countries after adjustment for age. Survival of incident patients (starting RRT during 2010) was calculated both from the start of RRT and from 90 days after starting RRT, both with and without censoring at transplantation. Prevalent dialysis patients were censored at transplantation; this means that the patient is considered alive up to the point of transplantation, but the patient's status post-transplant is not considered. Both Kaplan-Meier and Cox adjusted models were used to calculate survival. Causes of death were analysed for both groups. The relative risk of death was calculated compared with the general UK population.

Results: The unadjusted 1 year after 90 day survival for patients starting RRT in 2010 was 87.3%, representing an increase from the previous year (86.6%). In incident patients aged 18-64 years, the unadjusted 1 year survival had risen from 86.0% in patients starting RRT in 1997 to 92.6% in patients starting RRT in 2010 and for those aged ≥65 it had increased from 63.9% to 77.0% over the same period. The age-adjusted one year survival (adjusted to age 60) of prevalent dialysis patients increased from 88.1% in the 2001 cohort to 89.8% in the 2010 cohort. Prevalent diabetic patient one year survival rose from 82.1% in the 2002 cohort to 84.7% in the 2010 cohort. The age-standardised mortality ratio for prevalent RRT patients compared with the general population was 18 for age group 30-34 and 2.5 at age 85+ years. In the prevalent RRT dialysis population, cardiovascular disease accounted for 22% of deaths, infection and treatment withdrawal 18% each and 25% were recorded as other causes of death. Treatment withdrawal was a more frequent cause of death in those incident patients aged ≥65 than in younger patients. The median life years remaining for a 25-29 year old on RRT was 18 years and approximately three years for a 75+ year old.

Conclusions: Survival of patients starting RRT has improved in the 2010 incident cohort. The relative risk of death on RRT compared with the general population has fallen since 2001.
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http://dx.doi.org/10.1159/000353324DOI Listing
January 2014

Incidence of end-stage renal disease in the Turkish-Cypriot population of Northern Cyprus: a population based study.

PLoS One 2013 17;8(1):e54394. Epub 2013 Jan 17.

UCL Division of Medicine and Centre for Nephrology, University College London, London, United Kingdom.

Background: This is the first report of the incidence and causes of end-stage renal disease (ESRD) of the Turkish-Cypriot population in Northern Cyprus.

Methods: Data were collected over eight consecutive years (2004-2011) from all those starting renal replacement therapy (RRT) in this population. Crude and age-standardised incidence at 90 days was calculated and comparisons made with other national registries. We collected DNA from the entire prevalent population. As an initial experiment we looked for two genetic causes of ESRD that have been reported in Greek Cypriots.

Results: Crude and age-standardised incidence at 90 days was 234 and 327 per million population (pmp) per year, respectively. The mean age was 63, and 62% were male. The age-adjusted prevalence of RRT in Turkish-Cypriots was 1543 pmp on 01/01/2011. The incidence of RRT is higher than other countries reporting to the European Renal Association - European Dialysis and Transplant Association, with the exception of Turkey. Diabetes is a major cause of ESRD in those under 65, accounting for 36% of incident cases followed by 30% with uncertain aetiology. 18% of the incident population had a family history of ESRD. We identified two families with thin basement membrane nephropathy caused by a mutation in COL4A3, but no new cases of CFHR5 nephropathy.

Conclusions: This study provides the first estimate of RRT incidence in the Turkish-Cypriot population, describes the contribution of different underlying diagnoses to ESRD, and provides a basis for healthcare policy planning.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0054394PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3547872PMC
July 2013

UK Renal Registry 16th annual report: chapter 9 adequacy of haemodialysis in UK adult patients in 2012: national and centre-specific analyses.

Nephron Clin Pract 2013 14;125(1-4):171-81. Epub 2014 Feb 14.

UK Renal Registry, Bristol, UK.

Introduction: Outcomes in patients treated with haemodialysis (HD) are influenced by the delivered dose of dialysis. The UK Renal Association (RA) publishes clinical practice guidelines which include recommendations for dialysis dose. The urea reduction ratio (URR) is a widely used measure of dialysis dose and has historically been the measure of adequacy reported by the UKRR. This chapter aims to determine the extent to which patients achieved the recommended UK target.

Methods: All 71 UK renal centres submitted data to the UK Renal Registry (UKRR). Two groups of patients were included in the analyses: the prevalent HD patient population on 30st September 2012 and the incident HD patient population for 2011. Centres returning data on <50% of their patient population or centres with <20 patients were excluded from centrespecific comparisons.

Results: Data regarding URR were available from 63 renal centres in the UK. Forty nine centres provided URR data on more than 90% of prevalent HD patients. The proportion of patients in the UK who met the UK clinical practice guideline for URR (>65%) increased from 69% in 2000 to 88% in 2012. There was persistent variation observed between centres, with 21 centres attaining the RA clinical practice guideline in >90% of patients, 38 centres attaining the guideline in 70-90% of patients and one centre in less than 70% of patients. The overall proportion of prevalent HD patients with a URR >65% has continued to improve over time.

Conclusions: The delivered dose of HD, as measured by URR for patients with established renal failure, has increased over the last decade. Whilst the majority of UK patients achieved the target URR there was considerable variation between centres in the percentage of patients achieving the current guideline.
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January 2015
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