Why is there so much end-stage renal failure of undetermined cause in UK Indo-Asians?

Psychosocial well-being among individuals with chronic kidney disease undergoing hemodialysis treatment and their caregivers: a protocol of a mixed method study in Sri Lanka and Poland

Chronic Kidney Disease (CKD) can be identified as one of the non-communicable diseases (NCDs) which affect millions of people worldwide, including in Sri Lanka and Poland. The prevalence of CKD has been rising over the last three decades due to the identification of CKD with unknown etiology and the increment of NCDs such as hypertension and diabetes mellitus among the Sri Lankan population. Poland can be identified as a European country that has 4 million patients with CKD, which is the second most common chronic disease in the country. CKD is associated with the physical, economic, psychological, and social burden on patients and their caregivers. The current study is aimed to investigate the psychosocial well-being of CKD patients and their caregivers in Sri Lanka and Poland. The current study is a mixed-method study aimed to investigate the psychosocial well-being of individuals with chronic kidney disease undergoing hemodialysis and their caregivers in Sri Lanka and Poland. Participants in the quantitative part of the project will be individuals with chronic kidney disease undergoing hemodialysis from Sri Lanka (n = 63) and Poland (n = 63) who are currently undergoing hemodialysis treatment. Kidney Disease Quality of Life-Sort Form, Beck Depression Scale, Test of Self-Conscious Affect, The Courtauld Emotional Control Scale, Acceptance of Illness Scale, and a demographic and medical information sheet will be used in both Sri Lankan and Polish samples. Apart from that, the qualitative phase of the study will involve semi-structured interviews with individuals diagnosed with CKD, selected randomly from the initial part of the research, and their close relatives. Notably, the participant count will remain undetermined, as this approach addresses the inherent challenges of exploratory research.

Impact of Kidney Function on Cardiovascular Risk and Mortality: A Comparison of South Asian and European Cohorts

BACKGROUND

Evidence is limited on ethnic differences in associations between kidney function markers and mortality or cardiovascular disease (CVD).

METHODS

Baseline cross-sectional analysis and longitudinal follow-up study of a UK population-based cohort of 1,116 Europeans and 1,104 South Asians of predominantly Indian descent, age 52 ± 7 years at baseline (1988-1991). Kidney function was estimated using Cystatin C and creatinine-based chronic kidney disease (CKD) Epidemiology Collaboration estimated glomerular filtration rate (eGFR) equations, and urinary albumin-creatinine ratio (ACR). Mortality was captured at 27 years, and incident CVD at 22 years, from death certification, medical records and participant report. Longitudinal associations between eGFR/ACR and mortality/incident CVD were examined using Cox models.

RESULTS

eGFRcys was lower and ACR higher in South Asians than Europeans. eGFRcys and -eGFRcreat were more strongly associated with outcomes in Europeans than South Asians. Conversely, associations between ACR and outcomes were greater in South Asians than Europeans, for example, for CVD mortality: HRs (95% CI) adjusted for CVD risk factors and ACR/eGFRcys as appropriate, p for ethnicity interaction: eGFRcys: Europeans: 0.76 (0.62-0.92), South Asians: 0.92 (0.78-1.07), p = 0.05, eGFRcreat: Europeans 0.81 (0.67-0.99), South Asians 1.18 (0.97-1.41), p = 0.002, ACR: -Europeans: 1.24 (1.08-1.42), South Asians: 1.39 (1.25-1.57), p= 0.23. Addition of all CKD measures to a standard CVD risk factor model modestly improved prediction capability in -Europeans; in South Asians only ACR contributed to improvement.

CONCLUSIONS

Strong associations between ACR and outcomes in South Asians of predominantly Indian origin, and null associations for eGFRcys and eGFRcreat, suggest that ACR may have greater utility in CVD risk prediction in South Asians. Further work is needed to validate these -findings.

Factors influencing the higher incidence of tuberculosis among migrants and ethnic minorities in the UK

Migrants and ethnic minorities in the UK have higher rates of tuberculosis (TB) compared with the general population. Historically, much of the disparity in incidence between UK-born and migrant populations has been attributed to differential pathogen exposure, due to migration from high-incidence regions and the transnational connections maintained with TB endemic countries of birth or ethnic origin. However, focusing solely on exposure fails to address the relatively high rates of progression to active disease observed in some populations of latently infected individuals. A range of factors that disproportionately affect migrants and ethnic minorities, including genetic susceptibility, vitamin D deficiency and co-morbidities such as diabetes mellitus and HIV, also increase vulnerability to infection with Mycobacterium tuberculosis (M.tb) or reactivation of latent infection. Furthermore, ethnic socio-economic disparities and the experience of migration itself may contribute to differences in TB incidence, as well as cultural and structural barriers to accessing healthcare. In this review, we discuss both biological and anthropological influences relating to risk of pathogen exposure, vulnerability to infection or development of active disease, and access to treatment for migrant and ethnic minorities in the UK.

Factors influencing the higher incidence of tuberculosis among migrants and ethnic minorities in the UK

Migrants and ethnic minorities in the UK have higher rates of tuberculosis (TB) compared with the general population. Historically, much of the disparity in incidence between UK-born and migrant populations has been attributed to differential pathogen exposure, due to migration from high-incidence regions and the transnational connections maintained with TB endemic countries of birth or ethnic origin. However, focusing solely on exposure fails to address the relatively high rates of progression to active disease observed in some populations of latently infected individuals. A range of factors that disproportionately affect migrants and ethnic minorities, including genetic susceptibility, vitamin D deficiency and co-morbidities such as diabetes mellitus and HIV, also increase vulnerability to infection with Mycobacterium tuberculosis (M.tb) or reactivation of latent infection. Furthermore, ethnic socio-economic disparities and the experience of migration itself may contribute to differences in TB incidence, as well as cultural and structural barriers to accessing healthcare. In this review, we discuss both biological and anthropological influences relating to risk of pathogen exposure, vulnerability to infection or development of active disease, and access to treatment for migrant and ethnic minorities in the UK.

Chronic kidney disease hotspots in developing countries in South Asia

In many developing countries in the South Asian region, screening for chronic diseases in the community has shown a widely varying prevalence. However, certain geographical regions have shown a high prevalence of chronic kidney disease (CKD) of unknown etiology. This predominantly affects the young and middle-aged population with a lower socioeconomic status. Here, we describe the hotspots of CKD of undiagnosed etiology in South Asian countries including the North, Central and Eastern provinces of Sri Lanka and the coastal region of the state of Andhra Pradesh in India. Screening of these populations has revealed cases of CKD in various stages. Race has also been shown to be a factor, with a much lower prevalence of CKD in whites compared to Asians, which could be related to the known influence of ethnicity on CKD development as well as environmental factors. The difference between developed and developing nations is most stark in the realm of healthcare, which translates into CKD hotspots in many regions of South Asian countries. Additionally, the burden of CKD stage G5 remains unknown due to the lack of registry reports, poor access to healthcare and lack of an organized chronic disease management program. The population receiving various forms of renal replacement therapy has dramatically increased in the last decade due to better access to point of care, despite the disproportionate increase in nephrology manpower. In this article we will discuss the nephrology care provided in various countries in South Asia, including India, Bangladesh, Pakistan, Nepal, Bhutan, Sri Lanka and Afghanistan.

Smaller kidney size at birth in South Asians: findings from the Born in Bradford birth cohort study

BACKGROUND

Rates of advanced chronic kidney disease and renal replacement therapy are higher in South Asian than in white British populations. Low birth weight is also more frequent in South Asian populations and has been associated with increased risks of kidney disease, perhaps due to a reduced nephron endowment.

METHODS

Using ultrasound scans at 34 weeks of gestation, we measured fetal kidney dimensions (transverse and anteroposterior diameters, length and circumference) and derived volume in a random sample of 872 white British and 715 South Asian participants in the Born in Bradford cohort study. Kidney measurements were compared between ethnic groups.

RESULTS

Birth weight for gestational age at 40 weeks was 200 g less in South Asian babies compared with white British babies. The mean kidney volume for gestational age was 16% lower in South Asian than in white British babies [8.79 versus 10.45 cm(3), difference 1.66 cm(3) (95% confidence interval 1.40-1.93, P < 0.001)]. The difference was robust after adjustment for maternal age, socio-economic factors, marital status, body mass index, smoking and alcohol use in pregnancy, parity, baby's gender and birth weight for gestational age [adjusted difference 1.38 cm(3) (0.97-1.84), P < 0.001]. There were smaller reductions in other fetal measures.

CONCLUSION

South Asian babies have smaller kidneys compared with white British babies, even after adjusting for potential confounders including birth weight. This finding may contribute to increased risks of adult kidney disease in South Asian populations.

Cardiovascular health in migrants: current status and issues for prevention. A collaborative multidisciplinary task force report

OBJECTIVES

To review information on cardiovascular health and migration, to stress the attention of researchers that much needs to be done in the collection of sound data in Italy and to allow policy makers identifying this issue as an important public health concern.

BACKGROUND

In Italy, the rate of immigrants in the total number of residents increased from 2.5% in 1990 to 7.4% in 2010, and currently exceeds 10% in regions such as Lombardia, Emilia Romagna and Toscana.

METHODS

A consensus statement was developed by approaching relevant Italian national scientific societies involved in cardiovascular prevention. Task force members were identified by the president and/or the boards of each relevant scientific society or working group, as appropriate. To obtain a widespread consensus, drafts were merged and distributed to the scientific societies for local evaluation and revision by as many experts as possible. The ensuing final draft was finally approved by scientific societies.

RESULTS

In several western European countries, the prevalence of hypertension, diabetes, chronic kidney disease, obesity and metabolic syndrome was found to be higher among immigrants than in the native population. Although migrants are often initially healthier than non-migrant populations in their host countries, genetic factors, and changing environments with lifestyle changes, social exclusion and insufficient medical control may expose them to health challenges. Cultural reasons may also hamper both the dissemination of prevention strategies and migrant communication with healthcare providers. However, great diversity exists across and within different groups of migrants, making generalizations very difficult and many countries do not collect registry or survey data for migrant's health.

CONCLUSIONS

In the present economic context, the European Union is placing great attention to improve data collection for migrant health and to support the implementation of specific prevention policies aimed at limiting the future burden of cardiovascular and renal disease, and the consequent load for health systems. Wider initiatives on the topic are awaited in Italy.

Environmental exposures, socioeconomics, disparities, and the kidneys

Kidney disease disproportionately affects racial and ethnic minority populations, the poor, and the socially disadvantaged. The excess risk of kidney disease among minority and disadvantaged populations can only be partially explained by an excess of diabetes, hypertension, and poor access to preventive care. Disparities in the environmental exposure to nephrotoxicants have been documented in minority and disadvantaged populations and may explain some of the excess risk of kidney disease. High-level environmental and occupational exposure to lead, cadmium, and mercury are known to cause specific nephropathies. However, there is growing evidence that low-level exposures to heavy metals may contribute to the development of CKD and its progression. In this article, we summarize the excess risk of environmental exposures among minority and disadvantaged populations. We also review the epidemiologic and clinical data linking low-level environmental exposure to lead, cadmium, and mercury to CKD and its progression. Finally, we briefly describe Mesoamerican nephropathy, an epidemic of CKD affecting young men in Central America, which may have occupational and environmental exposures contributing to its development.

Developments in renal pharmacogenomics and applications in chronic kidney disease

Chronic kidney disease (CKD) has shown an increasing prevalence in the last century. CKD encompasses a poor prognosis related to a remarkable number of comorbidities, and many patients suffer from this disease progression. Once the factors linked with CKD evolution are distinguished, it will be possible to provide and enhance a more intensive treatment to high-risk patients. In this review, we focus on the emerging markers that might be predictive or related to CKD progression physiopathology as well as those related to a different pattern of response to treatment, such as inhibitors of the renin–angiotensin system (including angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers; the vitamin D receptor agonist; salt sensitivity hypertension; and progressive kidney-disease markers with identified genetic polymorphisms). Candidate-gene association studies and genome-wide association studies have analyzed the genetic basis for common renal diseases, including CKD and related factors such as diabetes and hypertension. This review will, in brief, consider genotype-based pharmacotherapy, risk prediction, drug target recognition, and personalized treatments, and will mainly focus on findings in CKD patients. An improved understanding will smooth the progress of switching from classical clinical medicine to gene-based medicine.

Association of CYP1A1 gene polymorphism with chronic kidney disease: a case control study

CYP1A1 is an important xenobiotic metabolizing enzyme, present in liver and kidney. Expression of CYP1A1 enzyme increases manifold when kidney cells are exposed to nephrotoxins/chemicals leading to oxidative stress-induced cell damage. To study the association of CYP1A1 gene polymorphism in patients of chronic kidney disease with unknown etiology (CKDU), we recruited 334 CKDU patients and 334 age and sex matched healthy controls. CYP1A1*2A and *2C polymorphisms were studied by PCR-RFLP and allele specific-PCR respectively. Subjects carrying at least one mutant allele of CYP1A1*2A (TC, CC) and *2C (AG, GG) were shown to be associated with 1.4-2-fold increased risk of CKDU. Also, genotypic combinations of hetero-/homozygous mutants of CYP1A1*2A (TC, CC) with hetero-/homozygous mutant genotypes of CYP1A1*2C (AG, GG) i.e. TC/AG (p<0.01), TC/GG (p<0.05), CC/AG (p<0.05) and CC/GG (p<0.01) were associated with CKDU with an odd ratio ranging 1.8-3.3 times approximately. This study demonstrates association of CYP1A1 polymorphisms with CKDU.

High normal levels of albuminuria and risk of hypertension in Indo-Asian population

BACKGROUND

Urine albumin excretion in the high normal range [urine albumin to creatinine ratio (UACR) 10-29 mg/g)] predicts hypertension in European-origin populations. However, the prognostic significance of UACR in the high normal range for incident hypertension is unclear in Indo-Asians. The objective of this study was to examine the relationship of normal to high normal levels of UACR and incident hypertension.

METHODS

We conducted a nested cohort study within a cluster randomized controlled trial in Pakistan on 1272 normotensive non-diabetic adults aged ≥ 40 years with UACR <30 mg/g. Incident hypertension was defined as new onset of systolic blood pressure (SBP) ≥ 140 mmHg or diastolic ≥ 90 mmHg or initiation of antihypertensive therapy.

RESULTS

A total of 920 (72.3%) participants completed the 2-year final follow-up. During this time, 105 (11.4%) developed incident hypertension. In the multivariable model, the odds [95% confidence interval (CI)] for incident hypertension were 2.45(1.21-4.98) for those in the fourth (top) quartile (≥ 6.1 mg/g) and 2.12 (1.04-4.35) in the third quartile (3.8-6.1 mg/g) compared to those in the lowest quartile (<2.8 mg/g). In addition, a significant interaction between UACR and baseline SBP was observed suggesting that the odds (95% CI) of incident hypertension with UACR were greater at lower baseline SBP (interaction P = 0.044).

CONCLUSIONS

High normal levels of albuminuria as measured by UACR predict hypertension in non-diabetic Indo-Asians, and this relationship may be enhanced in individuals with low baseline SBP. Further research is needed to assess the clinical applicability of these findings.

Enhanced complement activation is part of the unfavourable cardiovascular risk profile in South Asians

South Asian immigrants in western societies exhibit a high burden of diabetes and subsequent vascular complications. Diabetic vascular complications are associated with vascular inflammation. We hypothesize that enhanced complement activation is involved. Therefore, levels of complement C3 and SC5b-9 - the soluble end product of complement activation - in a group of 200 South Asians were compared with an age- and sex-matched control group of native Caucasians. In addition, the association between complement levels and albuminuria, an indicator of renal damage and a cardiovascular risk marker, was assessed in the diabetic South Asian group. Compared with native Caucasians, South Asians had significantly higher levels of both serum C3 and plasma SC5b-9, even when only non-diabetic South Asians were considered. Diabetic South Asians had significantly higher C3 levels compared with non-diabetic South Asians. In diabetic South Asians, higher levels of SC5b-9 were associated with an increased prevalence of albuminuria (odds ratio 5.4, 95% confidence interval 1.8-15.8). These results suggest that enhanced complement activation is part of the unfavourable cardiovascular risk profile in South Asians.

Ethnicity, age and incidence rates for renal replacement therapy (RRT) in Birmingham, UK: 1990-2004

BACKGROUND

Birmingham is a densely populated, industrial city with a high social deprivation index and large black (B) and Indo-Asian (I) populations. End stage renal failure is known to be more common in ethnic minorities and urban communities. Workforce planning requires accurate epidemiological data but most studies of the effect of ethnicity in the UK are from the early 1990s.

METHODS

RRT acceptance rates for adults (>16 years) in Birmingham were calculated for the 5-year periods 1990-5 and 1999-2004 using the 1991 and 2001 UK population census datasets and local programmes data.

RESULTS

The adult population of Birmingham Health Authority increased slightly (961,041 in 1991 v 977,099 in 2001) but the proportion of W fell (82.7% to 74.3%) while B (5.3% to 7.0%) and I (10.4% to 17.2%) both increased.Median age was lower for I (33.5 1991, 32.9 2001) than B(33.8 1991, 37.4 2001) and W (45.1 1991, 45.9 2001).Numbers of new patients increased by 29% in W, 98% in B and 109% in I. There was also a substantial increase in acceptance rates (W 92 to 129 pmp, I 175 to 243 pmp, B 191 to 278 pmp) but the proportional increase in I (26.9%) was less than in W (41.5%) or B (48.2%). This is because almost all the increase in RRT acceptance rates for all ethnic groups was seen in the over 55 age group (256 pmp 1991, 481 pmp 2001) but 85% of the population growth for I was in the under 55 age group. In all ethnic groups there was a striking increase in acceptance rates for the over 70's (W 177 to 440 pmp, I 536 to 1711 pmp, B 301 to 1858 pmp).

CONCLUSIONS

All acceptance rates were equivalent to the highest previously described in the UK. This may be due to local factors including social deprivation, availability of care and physicians attitudes. The increase in patient numbers was due to rising ethnic minority populations and increasing acceptance rates, especially in the elderly.The take-on rate is likely to rise disproportionately for I as the population ages over the next 10 years. This indicates that the future need for RRT in UK inner city areas, especially those with a large elderly ethnic population, will be greater than previously estimated.

Trends of incident dialysis patients in Tunisia between 1992 and 2001

BACKGROUND

Reliable information about the burden of end-stage renal disease (ESRD) is still scarce in the developing world.

STUDY DESIGN

Observational study of a national dialysis registry.

SETTING & PARTICIPANTS

Patients incident to dialysis therapy captured in the Tunisian registry of renal replacement therapy (RRT).

PREDICTOR

Intervals from 1992 to 2001.

OUTCOMES

Incidence rates of patients beginning dialysis therapy by age, sex, primary cause of ESRD, and region.

RESULTS

The incidence of treated ESRD dramatically rose in Tunisia during the 10-year period to reach 158.8 cases/million people in 2000 to 2001. We hypothesize that the Tunisian population is experiencing better access to RRT, a decrease in mortality from other causes, and an increase in chronic kidney diseases from chronic disease causes. Chronic diseases that develop with aging and economic development prevailed in urban environments, with diabetic nephropathy rising at the rate of 16.1%/y, whereas renovascular diseases, which include hypertensive nephropathy, rose by 7.6% annually. Interestingly, tubulointerstitial nephropathies increased by 10.4% each year, which may be related to such environmental risk factors as dietary exposure to ochratoxin A, especially in rural settings. ESRD from unknown causes or with missing information about cause increased by 12.7% yearly. Large regional differences in total incidence persist despite constant efforts to level off inequalities in access to health care facilities and RRT treatment.

LIMITATIONS

Possible underreferral for RRT, underreporting of cases, and misdiagnosis.

CONCLUSIONS

The growing incidence of patients on dialysis therapy in Tunisia emphasizes that preventing chronic kidney disease and its progression should be a public health priority.

Differences in Use of Peritoneal Dialysis and Survival Among East Asian, Indo Asian, and White ESRD Patients in Canada

BACKGROUND

Racial differences in health outcomes in general are well documented; however, few studies examined the impact of East Asian and Indo Asian race on choice of dialytic modality and survival among patients with end-stage renal disease (ESRD).

METHODS

We compared the use of peritoneal dialysis (PD) and survival among East Asian, Indo Asian, and white patients with ESRD initiating dialysis therapy in Canada between January 1, 1990, and December 31, 2000.

RESULTS

Of 10,338 patients, 5.7% were East Asian, 3.2% were Indo Asian, and 91% were white. After controlling for sociodemographics and comorbidities, East Asian and Indo Asian patients were significantly more likely to initiate dialysis therapy on PD compared with white patients (odds ratio, 1.63; 95% confidence interval [CI], 1.36 to 1.96; odds ratio, 1.52; 95% CI, 1.21 to 1.93, respectively), with no difference in likelihood of technique failure. East Asian and Indo Asian patients had a lower risk for death after the initiation of dialysis therapy (irrespective of modality) compared with white patients, with adjusted hazard ratios of 0.66 (95% CI, 0.58 to 0.76) for East Asian patients and 0.63 (95% CI, 0.53 to 0.75) for Indo Asian patients. The survival benefit for East Asian and Indo Asian patients was similar in the subgroup that initiated dialysis therapy with PD.

CONCLUSION

We found that Asian patients with ESRD were more likely to initiate dialysis therapy using PD, with improved survival after the initiation of dialysis therapy, compared with white patients. Elucidation of factors in East Asian and Indo Asian ESRD populations that result in improved outcomes may have implications for ESRD treatment for other racial groups.

Microalbuminuria and coronary heart disease risk in an ethnically diverse UK population: a prospective cohort study

Microalbuminuria (MA) is a strong risk factor for subsequent chronic disease, both renal and coronary heart disease (CHD), in European origin populations, but CHD risks differ by ethnicity, and it was hypothesized that prevalence of MA and relations with CHD may also differ. Combined analyses of two population-based cohorts started in 1988 and consisted of 1460 Europeans (70% male), 946 South Asians (78% male), and 559 African Caribbeans (51% male) who resided in London and were aged 40 to 69. Baseline fasting blood, overnight urine collection, and clinical measurements were performed. Prevalent CHD was defined by clinical history or major electrocardiogram changes. Age-adjusted albumin excretion rates (AER; geometric means, mug/min) were significantly higher in African Caribbeans (men: 6.1, 95% confidence interval [CI] 5.5 to 6.7; women: 5.7, 95% CI 5.2 to 6.2) than in South Asians (men: 4.3, 95% CI 4.0 to 4.5; women 3.4, 95% CI 3.0 to 3.8) and Europeans (men: 4.5, 95% CI 4.3 to 4.8; women: 3.3, 95% CI 3.1 to 3.6). MA was associated with both prevalent CHD and CHD mortality in South Asian men (hazard ratio 2.5; 95% CI 1.3 to 4.8) and in European women (hazard ratio 13.0; 95% CI 2.6 to 64.2) but not in any other group. Greater AER in African Caribbeans and the absence of association with CHD contrast with lower AER in South Asian men and European women, both strongly associated with CHD prevalence and mortality. These differences suggest that the pathogenesis of kidney disease and its link with CHD differ by ethnicity and gender.

Ethnicity and renal disease

BACKGROUND

Sexual function is one aspect of physical functioning. Sexual dysfunction, no matter the etiology, could cause distress. In female hemodialysis patients, sexual problems have often been neglected in clinical performance and research.

METHODS

We conducted this study by use of self-reported questionnaires. A total of 578 female hemodialysis patients in northern Taiwan were included in this study. Demographic data, comorbid diseases, medications in use, biochemical, and hematologic parameters were analyzed. All patients were asked to complete by themselves three questionnaires: (1) the Index of Female Sexual Function (IFSF) to assess sexual function; (2) the Beck Depression Inventory (BDI) (Chinese version) to rate the severity of depressive symptoms; and (3) the 36-item Short Form Health Survey Questionnaire (SF-36, Taiwan Standard Version 1.0) to survey their quality of life.

RESULTS

A total of 138 female patients were enrolled into further analysis. The mean age was 48.7 +/- 11.2 years old. The mean IFSF score was 24.5 +/- 9.3. Age, BDI score, and serum triglyceride levels were the independent factors of dysfunction in each sexual functional dimension. Patients with higher IFSF scores had significantly higher scores in physical functioning and mental health (P= 0.007 and 0.018, respectively). Patients with higher intercourse satisfaction had significantly higher general health scores (P= 0.001).

CONCLUSION

Sexual dysfunction is frequent in the female hemodialysis population. It is strongly associated with increasing age, dyslipidemia, and depression. The subjects with sexual dysfunction had poorer quality of life. The diagnosis and treatment of sexual dysfunction should be included in the clinical assessment.

Attitudes toward transplantation in U.K. Muslim Indo-Asians in west London

The worldwide shortage of organs for transplantation makes it important to understand why some oppose donation. Attitudes vary with religion and ethnicity. Accordingly, we undertook a qualitative study of the attitudes of 141 U.K. Muslim Indo-Asians to organ donation. Participants were observed, focus group discussions held and in-depth individual interviews conducted. We identified a high level of alienation from the health care system in general. With respect to organ donation in particular, its importance was generally discounted, often in deference to authority figures within the community who appeared negatively disposed. The culture-specific issues arguing against donation included a sense of the sacredness of the body, a fatalistic approach to illness, a belief that organs took on an independent role as 'witnesses' to an individual's life on Judgement Day and an anxiety that the donor would have no control of the probity of the recipient of an organ. We believe these data suggest a need to improve in a culturally sensitive fashion the provision of health information provided to this community.

Ethnicity and survival on dialysis in west London

BACKGROUND

Indo-Asian and Afro-Caribbean patients have higher rates of renal failure and requirement for renal replacement therapy than the general population in the UK. Despite this, information regarding survival on dialysis is limited.

METHODS

The incident hemodialysis population of a large west London renal service was reviewed from 1996 to 2001 (N = 465).

RESULTS

The cohort's ethnic background was Indo-Asian (30.8%), Caucasian (49%), Afro-Caribbean (18.3%), and other (1.9%). Indo-Asians and Afro-Caribbeans were younger than Caucasian patients, with a higher rate of diabetes mellitus. Survival on hemodialysis for Indo-Asians was 97.5% and 81.6% at 1 and 3 years, respectively, compared with 92.7% and 75.2% for Caucasians, and 97.5% and 85.3% for Afro-Caribbeans (P = nonsignificant). Dialysis adequacy was observed to be associated with survival. Patients with mean single pool Kt/V of over 1.4 had survival of 90.6% and 74.8% at 2 and 5 years, respectively, compared with 74.0% and 42.9% for those with Kt/V less than 1.4 (P < 0.001). There were significantly more patients in the Indo-Asian cohort with a mean Kt/V of 1.4 or over (87.4%) compared with Caucasians (57.6%) and Afro-Caribbeans (52.4%), and the benefit of higher Kt/V was seen in all ethnic groups. In a multivariate analysis of factors including Kt/V over 1.4, age, diabetic status, gender, and ethnicity, Indo-Asian or Afro-Caribbean ethnicity did not confer a survival disadvantage. The strongest predictors of survival were age and dialysis adequacy.

CONCLUSION

Indo-Asian and Afro-Caribbean hemodialysis patients have survival comparable to Caucasians despite a higher burden of diabetes.

Outcome of renal transplantation in South Asian recipients is similar to that in non-Asians

BACKGROUND

The United Kingdom has a large South Asian population, in which there is a high rate of renal disease and which forms a significant percentage of the renal transplant waiting list. Information about short- and long-term transplant outcomes in this ethnic group is limited, although it has been suggested that graft survival is poorer in this population compared with non-Asians.

METHODS

The authors examined the outcome and determinants of medium-term (5-year) survival in 245 renal transplants, 53 of which were performed in South Asian patients between 1995 and 2002.

RESULTS

Three-year survival with a functioning graft was 89% for the non-Asians and 85% for the South Asians. At 5 years, this deviated to 83% and 70%, respectively, for the two groups, but this did not reach statistical significance. Acute rejection rates were similar in the two groups. South Asian ethnicity was not a significant predictor of medium-term graft loss in the authors' study.

CONCLUSIONS

In this cohort of patients, South Asian ethnic background did not confer a survival disadvantage after renal transplantation.

Will transplantation of kidneys from donors with blood group A2 into recipients with blood group B help British Indo-Asian patients with renal failure?

Despite a high incidence of renal failure, disproportionately fewer Indo-Asians in the United Kingdom receive a renal transplant, in part because of the high prevalence of blood group B. It is now clear that it is possible to safely transplant kidneys from donors with blood group A of the subtype A2 into recipients with blood group B if the latter have low titers of anti-A antibodies. We measured the anti-A titers in 25 Indo-Asian patients on dialysis being considered for transplantation and found stably low titers in all. Titers were comparable to those found in a control white population with blood group B. In addition, in a complement-dependent cytotoxicity crossmatch against group A lymphocytes, the only positive results were obtained in those with high preexisting panel reactivity (i.e., because of the presence of preformed anti-human leukocyte antigen antibodies). We conclude that there are grounds for investigating this approach further to solve the ethnic disparity in rates of transplantation.

End-stage renal disease in Indo-Asians in the North-West of England

BACKGROUND

The incidence of end-stage renal disease (ESRD) in England is increasing. There is a higher incidence of ESRD in British Indo-Asians than in the White population.

AIM

To determine to what degree the increasing demand for renal replacement therapy in the UK is due to Indo-Asian patients. To study the presentation to renal services of Indo-Asian patients with ESRD and report any inequalities in initial treatment of Indo-Asian patients with ESRD compared to their White counterparts.

DESIGN

Prospective, inception cohort study.

METHODS

Consecutive adult patients with ESRD who started renal replacement therapy between 1 April 2000 and 31 December 2001 in all 14 renal units serving an area from North Cheshire to South Cumbria, including Greater Manchester and Lancashire, were recruited and interviewed.

RESULTS

Of the 578 patients, 9.5% were Indo-Asian. The annual acceptance rate for renal replacement therapy was 342 per million population in Indo-Asians, compared with 91 per million population in the White population ( p < 0.001). Indo-Asian patients with ESRD were younger (median age 51 years vs. 60 yrs, p = 0.006) and more socially deprived (81% vs. 36.5% in the 5th Carstairs quintile, p < 0.001). A greater proportion of Indo-Asian patients with ESRD presented late to specialist renal services (31% vs. 19%, p = 0.03). Once adjusting for their younger age, atherosclerotic renovascular disease and/or hypertensive nephropathy was more prevalent in Indo-Asian patients (OR 4.9; p = 0.03). There was no difference in the initial mode of maintenance dialysis or the perception of choice the patients felt they had, based on their ethnicity.

DISCUSSION

There is a silent epidemic of ESRD in Indo-Asian patients in the North-West, possibly vascular in aetiology, in which specialist intervention is late. This suggests that Indo-Asian patients should be prioritized for early intervention strategies to reduce the burden of ESRD.

Microalbuminuria is more frequent in South Asian than in European origin populations: a comparative study in Newcastle, UK

AIMS

We aimed to compare levels of urinary albumin excretion and the prevalence of microalbuminuria in UK South Asians and Europeans. Microalbuminuria predicts cardiovascular disease in European origin populations, but evidence from the general population of South Asians is lacking. Coronary heart disease (CHD) mortality is 40-50% higher in UK South Asians compared with the whole population, for reasons that are incompletely understood.

METHODS

Microalbuminuria was measured using the albumin-creatinine ratio in an age- and sex-stratified random sample of 1509 adults from European (n = 825), Indian (n = 259), Pakistani (n = 305) and Bangladeshi (n = 120) ethnic groups.

RESULTS

Levels of urinary albumin excretion were substantially higher in South Asians (geometric mean albumin creatinine ratio (95% confidence interval) 0.83 (0.75, 0.91)) than in Europeans (0.55 (0.51, 0.60)). Microalbuminuria was associated with older age, hypertension and diabetes, but independently of these risk factors urinary albumin excretion was higher in South Asians than Europeans.

CONCLUSIONS

Urinary albumin excretion is higher and microalbuminuria more frequent in UK South Asians compared with the majority ethnic population. Microalbuminuria may be relevant to the causal pathways leading to the excess of cardiovascular mortality and possibly renal failure in UK South Asians.

Genetics of diabetes complications

Long-term exposure to the hyperglycemia characteristic of diabetes patients leads to serious and frequently disabling or fatal complications. Emerging evidence suggests that genes are a significant contributor to an individual's risk of developing complications. This evidence is from evaluations of familial aggregation, differences in incidence in racial and ethnic groups, and statistical analysis of family data. Evidence to date suggests that complication genes are, distinct from the genes contributing to diabetes. Molecular geneticists have taken several approaches to identify genes contributing to complications, ranging from relatively simple analysis of specific candidate genes in small case-control comparisons to systematic evaluations of the human genome using genome scans and linkage analysis in large collections of families. Results suggest that genetic contributions to diabetes complications are diverse and complex in nature, presenting a significant challenge to researchers. Diabetes-affected families are frequently enriched for complications such as cardiovascular disease or nephropathy. In addition to their value in the study of diabetes complications, such families may be valuable resources for understanding cardiovascular disease and nephropathy in the nondiabetic population also.