Treatment of and mortality from diabetic renal failure in patients identified in the 1985 United Kingdom survey. Joint Working Party on Diabetic Renal Failure of the British Diabetic Association,Renal Association,and the Research Unit of the Royal College of Physicians.

The aim of the study was to determine the outcome in 181 diabetic patients with advanced, previously untreated renal impairment who had been identified in a survey conducted in six health regions in the United Kingdom in 1985. Late in 1987 questionnaires were sent to the consultant physicians, geriatricians, and nephrologists who had reported on the 181 patients, asking whether the patient had started receiving dialysis, had received a transplant, or had died. In all, 176 of the patients were traced, 164 having either died or received renal support treatment by the end of 1986. Nearly two thirds (107) of the patients received renal support treatment, which was renal transplantation in five and dialysis in 102. This is an increase on previous years. A third of the patients (57) died without having received renal support treatment. In 15 patients death was unavoidable and mainly from acute myocardial infarction (10 patients), but 28 patients (half of those who died untreated) died from renal failure, sometimes with fluid retention that was ascribed to heart failure (18 patients). Most of the patients would have benefited from renal support treatment. This neglect should no longer occur.     

HIV testing in patients with end stage renal disease.

One hundred and twenty eight British and Irish nephrologists were questioned about their policy for HIV testing of patients with end stage renal failure being considered for renal replacement therapy. A total of 101 (79%) replied. In the case of candidates for dialysis roughly one third of respondents tested only people they considered at risk of infection with HIV and nearly one fifth considered testing unnecessary. In the case of candidates for transplantation routine HIV testing was carried out by 68 of 100 nephrologists; 22 tested only patients "at risk" and 10 did not test. A positive HIV test result was considered by most but not all respondents (63/86) to exclude patients from transplantation. Twenty four of 88 nephrologists considered that HIV positivity should exclude patients from haemodialysis, but only seven of 87 would exclude such patients from peritoneal dialysis. Similar attitudes pertained for patients with end stage renal failure who refused HIV testing. Testing with the patient''s knowledge and consent was the policy of two thirds of nephrologists, but a patient''s signature was obtained by only 24 of 88. There should be a consensus on practice for HIV testing of patients with end stage renal failure.     

Successful treatment of middle aged and elderly patients with end stage renal disease.

Many patients over the age of 55 with end stage renal disease in the United Kingdom are denied dialysis or transplantation. Although the reasons are complex, anticipation of a poor prognosis for these patients might explain why most British renal units impose an arbitrary age limit on the acceptance of patients for treatment. A study was therefore conducted to examine the prognosis and quality of life of 84 patients (mean age 59.6 years, range 55-72) accepted into our renal replacement programme from the beginning of 1975. The five year survival of the patients was 62.0% with 78.1% of the survivors either having successful transplants or caring for themselves using home haemodialysis or continuous ambulatory peritoneal dialysis. The results show that in terms of survival, economics, and rehabilitation it is both feasible and reasonable to treat middle aged and elderly patients with end stage renal disease. These patients should therefore not be denied dialysis or transplantation on the basis of age alone, and the lack of resources and other factors that allow this state to persist in Britain should be rapidly redressed.     

Incidence of Uraemia and Requirements for Maintenance Haemodialysis

The biochemistry laboratory records of a 400-bed general hospital serving a population of about 120,000 showed that during the three-year period 1966-8 inclusive 487 patients had at some stage during their admission a blood urea of 100 mg/100 ml or more. Ninety per cent. were aged 50 or over, 79% were 60 or over, and 52% were 70 or over.The case notes of all patients with renal failure admitted during 1966 and 1967 were examined together with those of patients under 60 admitted during 1968. Three observers agreed about the most likely cause of the renal failure in 90% of patients whose case notes were available, or 74% of the total. The raised blood urea was thought to be due to “prerenal” factors in 60% of the patients, to acute tubular necrosis in 80%, to obstructive uropathy in 12%, and to “intrinsic” renal disease in 20%. Renal failure precipitated by such factors as cardiac failure, chest infections, cerebrovascular accidents, and shock was particularly common in old people.The hospital survey and replies to a questionnaire sent to all general practitioners in the area suggest that in the three-year period 14 patients may have been suitable for treatment by maintenance haemodialysis or renal transplantation. This represents a rate of about 39 per million per year under the age of 60 and 28 per million per year under 50.     

General practitioners' attitudes towards AIDS and their perceived information needs.

A short questionnaire on general practitioners'' self perceived and actual knowledge of AIDS and their attitudes to the illness was sent to 1824 general practitioners throughout the United Kingdom. The rate of response was 70%. Women doctors, those who trained overseas, and those who were married tended to have less positive attitudes towards patients with HIV and AIDS, whereas younger doctors, trainers, and members of the Royal College of General Practitioners were more understanding, better informed, and had more positive attitudes. Doctors with the least knowledge about HIV and AIDS and the most negative attitudes towards the illness would benefit from further education, which would be most effectively delivered through the professional journals, the Department of Health and the charitable AIDS organisations.     

Outcome of renal replacement treatment in patients with diabetes mellitus.

OBJECTIVE--To compare the outcome of renal replacement treatment in patients with diabetes mellitus and in non-diabetic patients with end stage renal failure. DESIGN--Retrospective comparison of cases and matched controls. SETTING--Renal unit, Western Infirmary, Glasgow, providing both dialysis and renal transplantation. PATIENTS--82 Diabetic patients starting renal replacement treatment between 1979 and 1988, compared with 82 matched non-diabetic controls with renal failure and 39 different matched controls undergoing renal transplantation. MAIN OUTCOME MEASURES--Patient characteristics, history of smoking, prevalence of left ventricular hypertrophy and myocardial ischaemia at start of renal replacement treatment; survival of patients with renal replacement treatment and of patients and allografts with renal transplantation. RESULTS--The overall survival of the diabetic patients during the treatment was 83%, 59%, and 50% at one, three, and five years. Survival was significantly poorer in the diabetic patients than the controls (p less than 0.001). Particularly adverse features for outcome at the start of treatment were increasing age (p less than 0.01) and current cigarette smoking (relative risk (95% confidence interval) 2.28 (0.93 to 4.84), p less than 0.05). Deaths were mainly from cardiac and vascular causes. The incidence of peritonitis in patients on continuous ambulatory peritoneal dialysis was the same in diabetic patients and controls (49% in each group remained free of peritonitis after one year), and the survival of renal allografts was not significantly worse in diabetic patients (p less than 0.5). CONCLUSIONS--Renal replacement treatment may give good results in diabetic patients, although the outlook remains less favourable than for non-diabetic patients because of coexistent, progressive vascular disease, which is more severe in older patients.     

Underprivileged areas: validation and distribution of scores.

Underprivileged areas were identified by weighting several census variables that relate to social conditions, by using weights determined by means of a questionnaire sent to one in 10 of the general practitioners in the United Kingdom. The weighted variables were added (after statistical manipulation) to give a score for each of the 9265 electoral wards in England and Wales. Blank ward maps were sent to general practitioners in five family practitioner committee areas and they were asked to shade the wards according to the degree to which the population increased their workload or the pressure on their services. Maps of these same areas were then prepared by using the calculated scores with the cut off points between the worst, the intermediate, and the best areas as on those used by the general practitioners. The two sets of maps were then compared to determine how well the maps that were based on scores agreed with the general practitioners'' maps showing their assessment of the variation of workload in their areas. Overall, 6.3% of the wards differed in shading in any way between the two sets of maps. In the three areas where the general practitioners shaded complete wards and did not report having difficulties with shading only 1.2% of the wards differed. It may be possible to use these "underprivileged area" scores to indicate where problems occur for general practitioners and to extend this work to other primary health care workers.     

Survival Rates of Patients Treated by Home and Hospital Dialysis and Cadaveric Renal Transplantation

Of 109 patients admitted to the renal failure programme of the Royal Free Hospital 80·7% were surviving after six years. For patients on home dialysis the four-year rate was 86·2%, more deaths occurring in women than in men. The short-term survival rate of all patients was high—namely, 96·3% at six months and 94·4% at 12 months. Hence large increases in the rate of acceptance of patients as well as successful transplantation are necessary to balance acceptance and loss from this programme.     

Kidney transplantation in Canada, 1981-84.

The Canadian Renal Failure Register was established in 1980. Data have been collected annually for all Canadian patients in whom irreversible kidney failure developed and who required dialysis or transplantation. The authors present actuarial patient and graft survival rates for 1981-84. In 1984, patients with a functioning renal graft accounted for 43.9% of the patients with end-stage renal disease. The number of transplants performed increased from 482 in 1981 to 662 in 1984; however, 1,022 patients undergoing dialysis (25.2%) were on an active waiting list for a transplant at the end of 1984. Greater effort is needed to increase the transplantation rate.     

Proteomics in extracorporeal blood purification and peritoneal dialysis

Extracorporeal blood purification and peritoneal dialysis are widely used in renal replacement therapy for patients with end-stage renal disease (ESRD) and acute kidney injury (AKI). Additionally, extracorporeal blood purification can be used also for treatment of non-renal disorders to remove endogenous or exogenous toxins from the blood circulation. Efforts have been made to characterize these toxins removed by diffusion (dialysis), convection (ultrafiltration), and/or adsorption (toxins are adsorbed onto the dialysis membrane and are thus removed) using different types of dialysis membrane. This review summarizes important findings obtained from recent proteomic studies applied to extracorporeal blood purification and peritoneal dialysis in settings of ESRD, AKI and hepatic failure.     

Is screening and intervention for microalbuminuria worthwhile in patients with insulin dependent diabetes?

OBJECTIVE--To analyse the cost-benefit of screening for and antihypertensive treatment of early renal disease indicated by microalbuminuria in patients with insulin dependent diabetes mellitus. DESIGN--Previously published data were used to estimate transition probabilities for each step from normoalbuminuria until death. The effect of intervention on urinary albumin excretion rate by antihypertensive treatment was arbitrarily set at three different levels. All direct costs (screening, antihypertensive treatment, treatment of end stage renal failure) were included in the cost-benefit analysis by using real discount rates of 2.5% and 6%. SETTING--Computer simulation. SUBJECTS--Simulated cohort of 8000 patients. MAIN OUTCOME MEASURES--Mortality, incidence of diabetic nephropathy, incidence of end stage renal failure, and costs versus savings. RESULTS--Assuming treatment effects of 33% and 67% median life expectancy increased by four to 14 years, respectively, and the need for dialysis or transplantation decreased by 21% to 63%. Costs and savings would balance if the annual rate of increase of albuminuria was decreased from 20% to 18% a year. CONCLUSIONS--Screening and intervention programmes are likely to have life saving effects and lead to considerable economic savings.     

Elevated levels of serum creatinine: recommendations for management and referral

BACKGROUND: The potential benefits of earlier referral to a nephrologist of patients with elevated levels of serum creatinine include identifying and treating reversible causes of renal failure, slowing the rate of decline associated with progressive renal insufficiency, managing the coexisting conditions associated with chronic renal failure and facilitating efficient entry into dialysis programs for all patients who might benefit. METHODS: A subcommittee of the Canadian Society of Nephrology, which included representatives from family practice and internal medicine, conducted a MEDLINE search for the period 1966 to 1998 using the key words referral and consultation, dialysis, hemodialysis, peritoneal dialysis, renal replacement therapy and kidney diseases. Where published evidence was lacking, conclusions were reached by consensus. GUIDELINES: Earlier referral to nephrologists of patients with elevated creatinine levels is expected to lead to better health care outcomes and lower costs for both the patients and the health care system. All patients with newly discovered renal insufficiency (as evidenced by serum creatinine elevated to a level above the upper limit of the normal range of that laboratory, adjusted for age and height in children) must undergo investigations to determine the potential reversibility of disease, to evaluate the prognosis and to optimize planning of care. All patients with an established, progressive increase in serum creatinine level should be followed with a nephrologist. Adequate preparation for dialysis or transplantation (or both) requires at least 12 months of relatively frequent contact with a renal care team. Nephrologists should provide consultation in a timely manner for any patient with an elevated serum creatinine level. In addition, they should provide advice about what aspects of the condition require particularly urgent or emergency assessment. SPONSORS: This clinical practice guideline has been endorsed by the Canadian Society of Nephrology and the College of Family Physicians of Canada. Meeting, teleconference and travel expenses of the Referral Guideline Subcommittee were covered by The Momentum Program, a collaboration between Baxter Corp. and Janssen-Ortho Inc. However, the authors are solely responsible for the editorial content of this article.     

Continuous ambulatory peritoneal dialysis after the honeymoon: review of experience in Newcastle 1979-84.

Two hundred and twenty nine consecutive patients (129 men, mean age 45) were reviewed 12 to 65 months after starting treatment with continuous ambulatory peritoneal dialysis (CAPD) from January 1979 to December 1983. They received CAPD for a mean of 19.8 (range 0.5-62) months. Actuarial patient survival was 79% at 24 months and 72% at 36 months. Half of the 46 deaths were related to cardiovascular disease, while eight patients died of abdominal complications, including three patients with peritonitis. Peritonitis occurred at a rate of one episode per 35 patient weeks, and 88% of episodes were cleared by one or more courses of antibiotics. This still left peritonitis as the commonest cause of failure of CAPD, leading to a permanent change of treatment in 44 patients and temporary interruption in a further 25. CAPD remains a reasonable medium term treatment in chronic renal failure. Despite the persisting problem of peritonitis the results are comparable with those achieved by haemodialysis, and CAPD has become the treatment of first choice for end stage renal failure in Newcastle. In younger patients judged unsuitable for transplantation and facing long term dialysis, however, haemodialysis is preferred.     

Substitutes for renal function. Technical trends and logistics of treatment

In France about 50 new patients per million of inhabitants per year with end stage renal disease (ESRD) require treatment with dialysis and/or transplantation. For the last few years new dialysis methods as hemofiltration and continuous ambulatory peritoneal dialysis have been extended. It is too early to predict what will be the role and the future of such methods as compared to hemodialysis, the gold standard. Appropriate logistics of treatment of ESRD rely on an integrated dialysis-transplantation program. In France the percentage of some modes of therapy, including home dialysis and transplantation, should be increased.     

Incidence of advanced chronic renal failure and the need for end stage renal replacement treatment.

OBJECTIVE--To determine the age related incidence of advanced chronic renal failure in two areas of England. DESIGN--Prospective study of patients newly identified as having advanced chronic renal failure within a two year period; subsequent monitoring of patients'' clinical course for a further 26 months. SETTING--Devon and Blackburn. SUBJECTS--Those patients in a population of 708,997 who developed advanced chronic renal failure (serum creatinine concentration greater than 500 mumol/l) for the first time during a two year period. MAIN OUTCOME MEASURES AND RESULTS--210 Patients (148 per million population per year) developed advanced chronic renal failure, 117 (51%) of whom were over 70. The age related incidence rose from 58 per million per year in those aged 20-49 to 588 per million per year in those aged 80 or over. Only 54% (113) of patients were referred to a nephrologist; 120 patients (57%) needed dialysis or died within three months of presenting without receiving dialysis, and 187 (89%) died or needed dialysis within three years. After those unsuitable for further treatment had been excluded, 78 patients per million population per year aged under 80 needed to start long term renal replacement treatment. CONCLUSIONS--Many patients suitable for renal replacement treatment are still not referred for nephrological opinion and are denied treatment. If the treatment rate in the United Kingdom rose from the 1988 rate of 55.1 per million per year to 78 per million per year then the number of patients receiving treatment would rise to about 800 per million. This is double the present number and has considerable but predictable resource implications for the NHS.     

Decontamination of instruments and control of cross infection in general practice.

OBJECTIVE--To assess the effectiveness of decontamination procedures in general practice. DESIGN--Anonymous postal questionnaire survey of 600 general practitioners randomly selected from the national register. SETTING--General practices throughout the United Kingdom. SUBJECTS--382 General practitioners, a response rate of 65%. RESULTS--186 General practitioners had autoclaves but 125 used hot water disinfectors or chemical disinfectants to reprocess instruments. 22% (474/2132) Of high risk instruments were inadequately decontaminated. Decontamination was performed by the practice nurse or receptionist in 306 practices. Knowledge of treatment of spillages of blood fluids was uncertain, and only 114 general practitioners used effective methods for dealing with spillages. CONCLUSIONS--A comprehensive central code of practice for control of infection is needed for primary health care staff.     

General practitioner obstetrics in the Northern region in 1983.

In late 1983 a four page questionnaire on general practitioner obstetrics was sent to a 50% random sample of general practitioners in the Northern region of England; 84% responded. Half of them said that they had access to general practitioner facilities for delivery, and half of these used them. A quarter of all respondents had provided intranatal care previously but had given it up, most of them during the late 1970s. Younger general practitioners were more highly qualified in obstetrics than older ones but did not do more intranatal work. Isolated general practitioner maternity units were much more likely to be used than those that were alongside consultant units or integrated with them. Ninety per cent of respondents provided antenatal care, 77% of these at special clinics and 88% with midwives in attendance. Teamwork, however, was not well developed. Increasing general practitioner participation in obstetric care seems feasible but depends heavily on more appropriate training and intranatal facilities being provided for general practitioners in association with specialist units.     

Obstetric Anaesthesia Services in the United Kingdom

In a survey of obstetric anaesthetic services in the United Kingdom questionnaires were sent to 398 hospital maternity units and 347 general-practitioner maternity units, of which 344 and 272 respectively were returned. Many hospitals were unable to provide an anaesthetist for obstetric surgery only, and few consultant anaesthetist sessions were allocated to obstetric surgery, particularly in regional hospitals in England and Wales. Constant supervision of junior anaesthetic staff with under 12 months'' experience was lacking in several hospitals. Endotracheal intubation is widely used throughout the United Kingdom. Though regional analgesic techniques are used by most anaesthetists it is impossible to provide a 24-hour regional analgesic service in all but a few hospitals.     

Prevention and treatment of osteoporosis in short stay departments of nursing homes: a nursing home physician's task

This research shows that nursing home physicians might play an important part in the diagnostics and treatment of vitamin-D deficiency. 96 rehabilitating elderly who had undergone a hip operation were investigated. 36% had a vitamin-D deficiency (vitamin-D < 30 nmol/l). Vitamin-D deficiency was 53 % in the fracture group and 26% in the arthritis group. Deficiencies were treated with vitamin-D medication. After the patient's discharge the general practitioner was sent a questionnaire. The results show that general practitioners agree to nursing home physicians' investigating vitamin-D deficiencies and to nursing home physicians' initiating vitamin-D medication in case of a deficiency. The general practitioners themselves do not often investigate vitamin-D deficiency.