Survival of patients treated with extended-hours haemodialysis in Europe : an analysis of the ERA-EDTA Registry

Background. Previous US studies have indicated that haemodialysis with >= 6-h sessions [extended-hours haemodialysis (EHD)] may improve patient survival. However, patient characteristics and treatment practices vary between the USA and Europe. We therefore investigated the effect of EHD three times weekly on survival compared with conventional haemodialysis (CHD) among European patients. Methods. We included patients who were treated with haemodialysis between 2010 and 2017 from eight countries providing data to the European Renal Association-European Dialysis and Transplant Association Registry. Haemodialysis session duration and frequency were recorded once every year or at every change of haemodialysis prescription and were categorized into three groups: CHD (three times weekly, 3.5-4h/treatment), EHD (three times weekly, >= 6h/treatment) or other. In the primary analyses we attributed death to the treatment at the time of death and in secondary analyses to EHD if ever initiated. We compared mortality risk for EHD to CHD with causal inference from marginal structural models, using Cox proportional hazards models weighted for the inverse probability of treatment and censoring and adjusted for potential confounders. Results. From a total of 142 460 patients, 1338 patients were ever treated with EHD (three times, 7.10.8h/week) and 89 819 patients were treated exclusively with CHD (three times, 3.9 +/- 0.2h/week). Crude mortality rates were 6.0 and 13.5/100 person-years. In the primary analyses, patients treated with EHD had an adjusted hazard ratio (HR) of 0.73 [95% confidence interval (CI) 0.62-0.85] compared with patients treated with CHD. When we attributed all deaths to EHD after initiation, the HR for EHD was comparable to the primary analyses [HR 0.80 (95% CI 0.71-0.90)]. Conclusions. EHD is associated with better survival in European patients treated with haemodialysis three times weekly.Peer reviewe

Trends in Mortality Due to Myocardial Infarction, Stroke, and Pulmonary Embolism in Patients Receiving Dialysis

IMPORTANCE During the past decades, improvements in the prevention and management of myocardial infarction, stroke, and pulmonary embolism have led to a decline in cardiovascular mortality in the general population. However, it is unknown whether patients receiving dialysis have also benefited from these improvements. OBJECTIVE To assess the mortality rates for myocardial infarction, stroke, and pulmonary embolism in a large cohort of European patients receiving dialysis compared with the general population. DESIGN, SETTING, AND PARTICIPANTS In this cohort study, adult patients who started dialysis between 1998 and 2015 from 11 European countries providing data to the European Renal Association Registry were and followed up for 3 years. Data were analyzed from September 2020 to February 2022. EXPOSURES Start of dialysis. MAIN OUTCOMES AND MEASURES The age- and sex-standardized mortality rate ratios (SMRs) with 95% CIs were calculated by dividing the mortality rates in patients receiving dialysis by the mortality rates in the general population for 3 equal periods (1998-2003, 2004-2009, and 2010-2015). RESULTS In total, 220 467 patients receiving dialysis were included in the study. Their median (IQR) age was 68.2 (56.5-76.4) years, and 82 068 patients (37.2%) were female. During follow-up, 83 912 patients died, of whom 7662 (9.1%) died because of myocardial infarction, 5030 (6.0%) died because of stroke, and 435 (0.5%) died because of pulmonary embolism. Between the periods 1998 to 2003 and 2010 to 2015, the SMR of myocardial infarction decreased from 8.1 (95% CI, 7.8-8.3) to 6.8 (95% CI, 6.5-7.1), the SMR of stroke decreased from 7.3 (95% CI, 7.0-7.6) to 5.8 (95% CI, 5.5-6.2), and the SMR of pulmonary embolism decreased from 8.7 (95% CI, 7.6-10.1) to 5.5 (95% CI, 4.5-6.6). CONCLUSIONS AND RELEVANCE In this cohort study of patients receiving dialysis, mortality rates for myocardial infarction, stroke, and pulmonary embolism decreased more over time than in the general population.Peer reviewe

Supplemented ERA-EDTA Registry data evaluated the frequency of dialysis, kidney transplantation, and comprehensive conservative management for patients with kidney failure in Europe

The aims of this study were to determine the frequency of dialysis and kidney transplantation and to estimate the regularity of comprehensive conservative management (CCM) for patients with kidney failure in Europe. This study uses data from the ERA-EDTA Registry. Additionally, our study included supplemental data from Armenia, Germany, Hungary, Ireland, Kosovo, Luxembourg, Malta, Moldova, Montenegro, Slovenia and additional data from Israel, Italy, Slovakia using other information sources. Through an online survey, responding nephrologists estimated the frequency of CCM (i.e. planned holistic care instead of kidney replacement therapy) in 33 countries. In 2016, the overall incidence of replacement therapy for kidney failure was 132 per million population (pmp), varying from 29 (Ukraine) to 251 pmp (Greece). On 31 December 2016, the overall prevalence of kidney replacement therapy was 985 pmp, ranging from 188 (Ukraine) to 1906 pmp (Portugal). The prevalence of peritoneal dialysis (114 pmp) and home hemodialysis (28 pmp) was highest in Cyprus and Denmark respectively. The kidney transplantation rate was nearly zero in some countries and highest in Spain (64 pmp). In 28 countries with five or more responding nephrologists, the median percentage of candidates for kidney replacement therapy who were offered CCM in 2018 varied between none (Slovakia and Slovenia) and 20% (Finland) whereas the median prevalence of CCM varied between none (Slovenia) and 15% (Hungary). Thus, the substantial differences across Europe in the frequency of kidney replacement therapy and CCM indicate the need for improvement in access to various treatment options for patients with kidney failure.Peer reviewe

Long-term prognosis with home hemodialysis. A comparison with other renal replacement therapies.

Background: The annual mortality for patients on dialysis is high even if it has decreased from 30 % in 1991 to 18 % in 2016. It is mainly caused by an increased cardiovascular and infectious morbidity. Previous studies have reported improved survival for patients with home hemodialysis (HHD). However, patients starting HHD are younger and healthier compared to patients starting other dialysis modalities. The aims of this thesis are to investigate the survival of Swedish patients starting with HHD as initial RRT, to analyse the major non-modifiable factors predicting survival and to study whether there is a benefit beyond patient selection in patient survival, health care utilization and subsequent renal graft survival for patients starting HHD compared with patients starting IHD or PD. An additional aim is to compare the effect on some modifiable risk factors between HHD and IHD. Methods:The studies in this thesis are retrospective observational studies based on data from patient records in study I and II and data from Swedish Renal Registry and the Swedish Inpatient Registry in study III and IV. In study I patients starting HHD at Lund University hospital 1971-1998 were included. In study II patients starting HHD at Lund University hospital 1983-2002 were matched with patients starting IHD at Malmö General Hospital. In study III and IV, all Swedish patients starting HHD during 1991-2012 were matched with patients starting IHD and PD. Matching was performed according to sex, age, Davies Comorbidity Index in study II, Charlson comorbidity index in study III-IV and date of start of dialysis, Results:The annual mortality for patients starting HHD in Lund was 4.9 %. Age, comorbidity and decade of start of HHD had a significant impact on survival. For patients younger than 60 years without comorbidies, subsequent renal transplantations did not have a significant impact on survival. (Study I)Patients starting HHD have a significant superior median survival, 18.5 years, compared with patients starting IHD, 11.9 years, or PD, 15.0 years (Study III).Patients starting HHD have less health care consumption measured as hospital admissions compared with IHD and PD. This advantage is partly caused by less admissions with cardiovascular diagnoses compared IHD and less admissions with infectious disease diagnoses and longer dialysis technique survival compared with PD. (Study IV).There was no significant difference in subsequent renal graft surival after HHD compared to IHD or PD (Study III). Contributing modifiable factors to the improved prognosis for patients on HHD are less prescribed antihypertensives and diuretics, as indirect measures of improved fluid balance, and lower phosphate levels, compared to patients on IHD. (Study II)Conclusion: Patients starting HHD as initial RRT exhibit an improved long-term prognosis beyond differences in patient selection, a superior survival and less health care utilization, compared with patients starting IHD or PD. The results of this thesis are strong incentives for increased use of HHD for patients on maintenance dialysis

The effect of peritoneal dialysis on labor market outcomes compared with institutional hemodialysis

BACKGROUND: The aim of this study is to compare the impact of peritoneal dialysis (PD) and institutional hemodialysis (IHD), the 2 most common dialysis modalities, on employment, work income, and disability pension in Sweden.METHODS: Included in this study were 4,734 patients in IHD and PD, aged 20 - 60 years, starting treatment in Sweden during 1995 - 2012, and surviving the first year of dialysis therapy. Both "intention to treat" and "on treatment" analyses were performed by including transplant patients into the former and censoring them at the date of transplant in the latter analysis. A reduced bias treatment effect of PD vs IHD on labor market outcomes was esti-mated while accounting for non-random selection into treatment.RESULTS: Peritoneal dialysis was found to be associated with a 4-percentage-point increased probability of employment compared with IHD in the "on treatment" analysis. Also, PD was associated with a reduced disability pension by 6 percentage points, as well as increased work income (EUR 3,477 for employed) compared with IHD during the first year of treatment. The "intention to treat" analysis tended to give higher effect sizes compared with "on treatment."CONCLUSIONS: The results indicate that PD is associated with a treatment advantage over IHD in terms of increased employment, work income, and reduced disability pension in the Swedish popu-lation after controlling for non-random selection into treatment

Home- or Institutional Hemodialysis? - a Matched Pair-Cohort Study Comparing Survival and Some Modifiable Factors Related to Survival

Background/Aims: Survival for dialysis patients is poor. Earlier studies have shown better survival in home-hemodialysis (HHD). The aims of this study are to compare survival for matched patients with HHD and institutional hemodialysis (IHD) and to elucidate the effect on factors related to survival such as hyperphosphatemia, fluid overload and anemia. Methods: In this retrospective, observational study, incident patients starting HHD and IHD were matched according to sex, age, comorbidity and date of start. Survival analysis was performed both as ”intention to treat” including renal transplantation and ”on treatment” with censoring at the date of transplantation. Dialysis doses, laboratory parameters and prescriptions of medications were compared. Results: After matching, 41 pairs of patients, with HHD and IHD, were included. Survival among HHD patients was longer compared with IHD, median survival being 17.3 and 13.0 years (p=0.016), respectively. The “on treatment” analysis, also favoured HHD (p=0.015). HHD patients had lower phosphate, 1.5 mmol/L compared with 2.1 mmol/L (

Quantifying the treatment effect of kidney transplantation relative to dialysis on survival time : New results based on propensity score weighting and longitudinal observational data from Sweden

Using observational data to assess the treatment effects on outcomes of kidney transplantation relative to dialysis for patients on renal replacement therapy is challenging due to the non-random selection into treatment. This study applied the propensity score weighting approach in order to address the treatment selection bias of kidney transplantation on survival time compared with dialysis for patients on the waitlist. We included 2676 adult waitlisted patients who started renal replacement therapy in Sweden between 1 January 1995, and 31 December 2012. Weibull and logistic regression models were used for the outcome and treatment models, respectively. The potential outcome mean and the average treatment effect were estimated using an inverse-probability-weighted regression adjustment approach. The estimated survival times from start of renal replacement therapy were 23.1 years (95% confidence interval (CI): 21.2−25.0) and 9.3 years (95% CI: 7.8−10.8) for kidney transplantation and dialysis, respectively. The survival advantage of kidney transplantation compared with dialysis was estimated to 13.8 years (95% CI: 11.4−16.2). There was no significant difference in the survival advantage of transplantation between men and women. Controlling for possible immortality bias reduced the survival advantage to 9.1–9.9 years. Our results suggest that kidney transplantation substantially increases survival time compared with dialysis in Sweden and that this consequence of treatment is equally distributed over sex

Socioeconomic inequalities in the kidney transplantation process : A registry-based study in Sweden

Background. Few studies have examined the association between individual-level socioeconomic status and access to kidney transplantation. This study aims to investigate the association between predialysis income and education, and access to (i) the kidney waitlist (first listing), and (ii) kidney transplantation conditional on waitlist placement. Adjustment will be made for a number of medical and nonmedical factors. Methods. The Swedish Renal Register was linked to national registers for adult patients in Sweden who started dialysis during 1995 to 2013. We employed Cox proportional hazards models. Results. Nineteen per cent of patients were placed on the waitlist. Once on the waitlist, 80% received kidney transplantation. After adjusting for covariates,patients in the highest income quintile were found to have higher access to both the waitlist (hazard ratio [HR], 1.73; 95% confidence interval [CI], 1.53-1.96) and kidney transplantation (HR, 1.33; 95% CI, 1.16-1.53) compared with patients in the lowest incomequintile. Patients with higher education also had better access to the waitlist and kidney transplantation (HR, 2.16; 95% CI, 1.94-2.40; and HR, 1.16; 95% CI, 1.03-1.30, respectively) compared with patients with mandatory education. Conclusions. Socioeconomic status-related inequalities exist with regard to both access to the waitlist, and kidney transplantation conditional on listing. However, the former inequality is substantially larger and is therefore expected to contribute more to societal inequalities. Further studies are needed to explore the potential mechanisms and strategies to reduce these inequalities

A guide to environmental legislation on ground. An Internet based guide to planning, design and construction

(1) Innehåll och uppläggning; (2) Teknisk uppbyggnad; (3) Nyttiggörande och implementering; (4) Förslag till projektutveckling; Bilagor: (1) Referensgrupp; (2) Seminarium i Stockholm den 9 oktober 200