Kidney international
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Kidney international · Sep 2006
Comparative StudyAssociation between residence location and likelihood of kidney transplantation in Aboriginal patients treated with dialysis in Canada.
For reasons that are not well understood, Aboriginal people with end-stage renal disease (ESRD) have lower rates of kidney transplantation. We hypothesized that distance between residence location and the closest transplant center was greater in Aboriginal dialysis patients and would partially explain the lower rate of transplantation in this population. We studied a random sample of 9905 patients initiating dialysis in Canada between 1990 and 2000. ⋯ For example, the relative likelihood of transplantation was hazard ratio (HR) 0.47, 95% confidence interval (CI) (0.31-0.72) in Aboriginal participants residing
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Kidney international · Sep 2006
Comparative StudyMortality after acute renal failure: models for prognostic stratification and risk adjustment.
To adjust adequately for comorbidity and severity of illness in quality improvement efforts and prospective clinical trials, predictors of death after acute renal failure (ARF) must be accurately identified. Most epidemiological studies of ARF in the critically ill have been based at single centers, or have examined exposures at single time points using discrete outcomes (e.g., in-hospital mortality). We analyzed data from the Program to Improve Care in Acute Renal Disease (PICARD), a multi-center observational study of ARF. ⋯ Models incorporating time-varying covariates enhanced predictive power by reducing misclassification and incorporating day-to-day changes in extra-renal organ system failure and the provision of dialysis during the course of ARF. Using data from the PICARD multi-center cohort study of ARF in critically ill patients, we developed several predictive models for prognostic stratification and risk-adjustment. By incorporating exposures over time, the discriminatory power of predictive models in ARF can be significantly improved.
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Kidney international · Sep 2006
Comparative StudySustained low-efficiency dialysis in the ICU: cost, anticoagulation, and solute removal.
Hemodialysis (HD) for critically ill patients with acute renal failure has been provided as intermittent hemodialysis (IHD) or continuous renal replacement therapy (CRRT). IHD is often complicated by hypotension and inadequate fluid removal, and CRRT by high cost of solutions and problems with anticoagulation. Sustained low-efficiency daily dialysis (SLED) has been suggested as an alternative treatment. ⋯ Sixty-five percent of SLED treatments were heparin-free; filter clotting occurred in 18% of heparin treatments and 29% of heparin-free treatments (NS). Weekly Kt/V was significantly higher for SLED (8.4+/-1.8) and time-averaged serum creatinine was lower; equivalent renal clearance (EKRjc) was 29+/-6 ml/min for SLED, similar to that for CRRT. In summary, SLED may be routinely performed without anticoagulation; it provides solute removal equivalent to CRRT at significantly lower cost.
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Dialysis rationing resulting from limited facilities and health-care personnel in low- and middle-income countries such as South Africa must be addressed on several fronts. Prevention of kidney disease is an essential long-term approach, but in the short term, it is necessary to increase access to dialysis and transplantation, and to seek ways to limit the 'brain drain' to the developed world.