The 1999 Canadian vascular access guidelines recommend the fistula as the access of choice. The study describes the trends in hemodialysis access use, variation among provinces, and the association ...with mortality from 2001 to 2004.
An observational study of adult patients registered in Canadian Organ Replacement Registry on hemodialysis. Access trends were examined among incident and prevalent hemodialysis patients adjusted for age, sex, body mass index, late referral, race, smoking status, province, etiology of end-stage renal disease, and comorbidities. Cox proportional hazard regression analysis was used to analyze risk for death for patients followed to December 31, 2005.
From 2001 to 2004, incident catheter use increased from 76.8% to 79.1%, fistulas decreased from 21.6% to 18.6%, and grafts remained between 2.1% to 2.6%. Prevalent catheter use increased from 41.8% to 51.7%, and fistulas and grafts decreased from 46.8% to 41.6% and 11.4% to 6.7%, respectively. There was significant variation in incident and prevalent fistulae use among the provinces. Adjustment for differences in patient characteristics did not change these trends. Incident catheter use was associated with a 6 times greater risk of death compared with fistula or graft use combined.
In Canada there has been a decrease in fistulae and grafts with a subsequent increase in catheters that is not explained by changes in patient characteristics. Vascular access use varied by province, suggesting differences in practice patterns. Because incident catheter use was associated with increased mortality, urgent measures are needed to develop strategies to decrease catheter use.
Over the past decade, there has been a steep rise in the number of people with complex medical problems who require dialysis. We sought to determine the life expectancy of elderly patients after ...starting dialysis and to identify changes in survival rates over time.
All patients aged 65 years or older who began dialysis in Canada between 1990 and 1999 were identified from the Canadian Organ Replacement Register. We used Cox proportional hazards models to examine the effect that the period during which dialysis was initiated (era 1, 1990-1994; era 2, 1995-1999) had on patient survival, after adjusting for diabetes, sex and comorbidity. Patients were followed from initiation of dialysis until death, transplantation, loss to follow-up or study end (Dec. 31, 2004).
A total of 14,512 patients aged 65 years or older started dialysis between 1990 and 1999. The proportion of these patients who were 75 years or older at the start of dialysis increased from 32.7% in era 1 (1990-1994) to 40.0% in era 2 (1995-1999). Despite increased comorbidity over the 2 study periods, the unadjusted 1-, 3- and 5-year survival rates among patients aged 65-74 years at dialysis initiation rose from 74.4%, 44.9% and 25.8% in era 1 to 78.1%, 51.5% and 33.5% in era 2. The respective survival rates among those aged 75 or more at dialysis initiation increased from 67.2%, 32.3% and 14.2% in era 1 to 69.0%, 36.7% and 20.3% in era 2. This survival advantage persisted after adjustment for diabetes, sex and comorbidity in both age groups (65-74 years: hazard ratio HR 0.76, 95% confidence interval CI 0.72- 0.81; 75 years or more: HR 0.86, 95% CI 0.80-0.92).
Survival after dialysis initiation among elderly patients has improved from 1990 to 1999, despite an increasing burden of comorbidity. Physicians may find these data useful when discussing prognosis with elderly patients who are initiating dialysis.
Accurate and complete documentation of patient characteristics and comorbidities in renal registers is essential to control bias in the comparison of outcomes across groups of patients or dialysis ...facilities. The objectives of this study were to assess the quality of data collected in the Canadian Organ Replacement Register (CORR) compared with the patient's medical charts.
This cohort study of a representative sample of adult, incident patients registered in CORR in 2005 to 2006 examined the prevalence, sensitivity, specificity, positive and negative predictive values, and κ of comorbid conditions and agreement in coding of patient demographics and primary renal disease between CORR and the patient's medical record. The effect of coding variation on patient survival was evaluated.
Medical records on 1125 patients were reviewed. Agreement exceeded 97% for health card number, date of birth, and sex and 71% (range 46.6 to 89.1%) for the primary renal disease. Comorbid conditions were under-reported in CORR. Sensitivities ranged from 0.89 (95% confidence interval 0.80, 0.92) for hypertension to 0.47 (0.38, 0.55) for peripheral vascular disease. Specificity was >0.93 for all comorbidities except hypertension. Hazard ratios for death were similar whether calculated using data from CORR or the medical record.
Comorbid conditions are under-reported in CORR; however, the associated risks of mortality were similar whether using the CORR data or the medical record data, suggesting that CORR data can be used in clinical research with minimal concern for bias.
Data of incident hemodialysis patients from 2001 to 2007 were abstracted from The Renal Disease Registry (TRDR) from central Ontario, Canada and followed until December 2008 to determine 90-day ...mortality rates for incident hemodialysis patients. Modifiable risk factors of early mortality were determined by a Cox model. In total, 876 of 4807 incident patients died during their first year on dialysis; 304 (34.7%) deaths occurred within the first 90 days of dialysis initiation. The majority of deaths were attributed to a cardiovascular event or infection and more likely occurred in older patients and those with cardiovascular co-morbidities. Of potentially modifiable risk factors, low body mass index (<18.5), a surrogate for malnutrition, was a strong predictor of early mortality adjusted hazard ratio (HR) 4.22 (CI: 3.12–5.17). Also, central venous catheter use was associated with a 2.40 fold increase risk of death (CI: 1.4–3.90). Patients who attended a multidisciplinary pre-dialysis clinic were less likely to die (HR: 0.60, CI: 0.47–0.78). The first 90 days after initiation of dialysis is a period of especially high risk of death. We have identified potentially modifiable risk factors in vascular access type, pre-dialysis care and nutritional status.
There were 35 265 patients receiving renal replacement therapy in Canada at the end of 2007 with 11.0% of patients on peritoneal dialysis (PD) and 48.9% on hemodialysis (HD) and a remaining 40.1% ...living with a functioning kidney transplant. There are no contemporary studies examining PD survival relative to HD in Canada. The objective was to compare survival outcomes for incident patients starting on PD as compared to HD in Canada.
Using data from the Canadian Organ Replacement Register, the Cox proportional hazards (PH) model was employed to study survival outcomes for patients initiating PD as compared to HD in Canada from 1991 to 2004 with follow-up to 31 December 2007. Comparisons of outcomes were made between three successive calendar periods: 1991-95, 1996-2000 and 2001-04 with the relative risk of death of incident patients calculated using an intent-to-treat (ITT) analysis with proportional and non-PH models using a piecewise exponential survival model to compare adjusted mortality rates.
In the ITT analysis, overall survival for the entire study period favored PD in the first 18 months and HD after 36 months. However, for the 2001-04 cohort, survival favored PD for the first 2 years and thereafter PD and HD were similar. Among female patients > 65 years with diabetes, PD had a 27% higher mortality rate.
Overall, HD and PD are associated with similar outcomes for end-stage renal disease treatment in Canada.
Aims: To determine if rates of diabetic and non‐diabetic end‐stage renal disease (ESRD), which had been rising in young and middle‐aged adults in all populations up to the mid‐1990s, had started to ...decline, and if so, whether improvement had occurred in respect of each of the principal primary renal diseases causing ESRD.
Methods: Poisson regression of age‐ and sex‐standardized incidence of ESRD for persons aged 20–64 years in 18 populations from Europe, Canada and the Asia‐Pacific region, for 1998–2002.
Results: In persons from 12 European descent (Europid) populations combined, there was a small downward trend in all‐cause ESRD (−1.7% per year, P = 0.001), with type 1 diabetic ESRD falling by 7.8% per year (P < 0.001), glomerulonephritic ESRD by 3.1% per year (P = 0.001), and ‘all other non‐diabetic’ ESRD by 2.5% per year (P = 0.02). The reductions in ESRD attributed to hypertensive (−2.2% per year) and polycystic renal disease (−1.5% per year) and unknown diagnosis (−0.2% per year) were not statistically significant. On the other hand, the incidence of type 2 diabetic ESRD rose by 9.9% per year (P < 0.001) in the combined Europid population, although that of (principally type 2) diabetic ESRD remained unchanged in the pooled data from the four non‐Europid populations.
Conclusion: Recent preventive strategies, probably chiefly modern renoprotective treatment, appear to have been effective for tertiary prevention of ESRD caused by the proteinuric nephropathies other than type 2 diabetic nephropathy, for which the continuing increase in Europid populations represents a failure of prevention and/or a change in the nephropathic potential of type 2 diabetes.
In Australia, Canada, New Zealand, and the United States indigenous people have high rates of chronic kidney disease but poor access to effective therapies. To more fully define these issues, we ...compared the demographics of renal transplantation of indigenous patients in these 4 countries. Data encompassing 312,507 indigenous and white patients (18–64 years of age) who initiated dialysis within an 11-year period ending in 2005 were obtained from each country's end-stage kidney disease registry. By the study's end, 88,173 patients had received a renal transplant and 130,261 had died without receiving such. Compared with white patients, the adjusted likelihood of receiving a transplant for indigenous patients was significantly lower in Australia (hazard ratio (HR) 0.23), Canada (HR 0.34), New Zealand (HR 0.23), and the United States (HR 0.44). In all four countries, indigenous patients had significantly longer overall median waiting times compared to white patients. Our study shows that despite marked differences in health care delivery systems, indigenous patients are less likely than white patients to receive a renal transplant in these countries. Understanding and addressing barriers to renal transplantation of indigenous patients remains an important concern.
Chronic kidney disease is associated with increased mortality among nonrenal organ transplant recipients. End-stage renal disease (ESRD) is a serious complication after orthotopic liver ...transplantation (OLT). It is unclear if the outcomes of these individuals are different from nontransplant patients requiring dialysis or a kidney transplant.
We report the incidence of ESRD in OLT recipients and compare their outcomes to matched dialysis controls. We analyzed 4186 patients who received an OLT in Canada between January 1981 and December 2002 and 228 matched, nontransplant, chronic dialysis controls.
The incidence of ESRD after OLT was 2.9% (n=120). The unadjusted mortality rate for those who required chronic dialysis was 49.2% compared with 26.8% in those who did not develop kidney failure (P<0.0001). The survival of OLT recipients on dialysis was lower than the matched chronic dialysis cohort (log-rank test, P=0.01). A kidney transplant was performed in 24% of the OLT recipients and 21% of the matched dialysis cohort, and their overall survival was similar. The OLT patients who remained on dialysis had a significantly lower survival when compared with matched dialysis patients who did not receive a kidney transplant (log-rank test, P=0.0002).
Mortality was greater for OLT recipients on dialysis than would be expected from a matched, nontransplant, dialysis cohort. Kidney transplantation may abrogate some of this increased mortality risk.
Studies from the United States have shown that renal allograft failure is associated with a high mortality rate. The purpose of this study was to determine whether transplant failure was associated ...with survival in a recent cohort of kidney transplant recipients with different characteristics and a distinct health care system from the United States. Cox regression was used to model allograft loss as a time‐dependent variable with patient survival as the primary outcome in 4743 kidney transplant recipients from the Canadian Organ Replacement Register. During follow‐up 607 (12.8%) patients had allograft failure and 411 (8.7%) died. Patients with a functioning transplant had an unadjusted death rate of 2.06 per 100 patient years that increased to 5.14 per 100 patient years following allograft failure. After controlling for important confounding variables, allograft failure was found to increase the risk of death by over threefold compared to patients who maintained transplant function (adjusted hazard ratio, 3.39; 95% CI, 2.75–4.16; p < 0.0001). In conclusion, this analysis has shown that kidney transplant failure is an independent predictor of mortality following renal transplantation in a Canadian population. This finding supports the premise that it is the loss of transplant function, rather than patient or system‐related issues, that is the main factor contributing to outcome.
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