Variation in dialysis patient mortality by Health Authority

Focus on the Gut-Kidney Axis in Health and Disease

The recent new developments in technology with culture-independent techniques including genome sequencing methodologies shed light on the identification of microbiota bacterial species and their role in health and disease. Microbiome is actually reported as an important predictive tool for evaluating characteristic shifts in case of disease. Our present review states the development of different renal diseases and pathologies linked to the intestinal dysbiosis, which impacts on host homeostasis. The gastrointestinal–kidney dialogue provides intriguing features in the pathogenesis of several renal diseases. Without any doubt, investigation of this interconnection consists one of the most cutting-edge areas of research with potential implications on our health.

Higher mortality among remote compared to rural or urban dwelling hemodialysis patients in the United States

Living far away from specialized care centers is a potential barrier to the delivery of quality health care and has been associated with adverse outcomes. To assess mortality as a function of distance from the closest hemodialysis unit, and as a function of rural rather than urban residence, we analyzed prospectively collected data on 726,347 adults initiating chronic hemodialysis in the United States over a 13-year period. Participants were classified into categories of 0-10 (referent), 11-25, 26-45, 46-100, and remote living over 100 miles from the closest hemodialysis unit. After a median follow-up of 2.7 years (range 0 to 12.7 years), 368,569 patients died. Compared to the referent group, the adjusted hazard ratio of death was 1.01, 0.99, 0.96, and 1.21, respectively. When residence location was classified using rural-urban commuter areas, 16.5, 66.8, and 16.7% of patients lived in urban, micropolitan, and metropolitan areas, respectively. Compared with those living in metropolitan areas, the adjusted hazard ratio of mortality among patients residing in micropolitan and rural communities was 1.02 and 1.01, respectively. Thus, remote but not rural residence was associated with increased mortality among patients initiating chronic hemodialysis treatment in the United States.

Social deprivation and survival on renal replacement therapy in England and Wales

This study examines the association between social deprivation and patient characteristics and outcomes in a nationally representative cohort of incident renal replacement therapy (RRT) patients. All Caucasian patients reported to the UK Renal Registry between 1997 and 2004 by centers in England and Wales with high data completeness were included. Social deprivation was assessed using the Townsend index. Socially deprived patients were more likely to be referred late. They were less likely to receive peritoneal dialysis (25.1 vs 34.8% on day 1, P trend <0.0001) or a renal transplant (5.3 vs 12.4% at 1 year, P trend <0.0001), and were less likely to attain UK Renal Association standards for hemoglobin and phosphate at 1 year. Crude survival decreased significantly with increasing deprivation for patients under the age of 65 years, but not for those aged 65 years and above (likelihood ratio for age-social deprivation interaction P<0.0001). Social deprivation was significantly associated with poorer survival after adjustment for age, gender, and cause of renal failure. After adjusting for baseline co-morbidity, social deprivation was no longer associated with poorer survival. Baseline differences in co-morbidity seem to explain poorer crude survival in incident Caucasian RRT patients from socially deprived areas in England and Wales. Differences also exist in some processes of care and intermediate outcomes, which may be amenable to intervention.

Dialysis and kidney transplantation among patients living in rural areas of the United States

Although one-fifth of the United States population is rural, little is known about the characteristics and outcomes of rural dialysis patients. We measured the association of rural residence with patient characteristics, survival, and time to transplant among 552,279 patients who initiated dialysis between January 1, 1995 and December 31, 2002 and survived more than 90 days. We also examined the characteristics of 4363 Medicare-certified dialysis facilities by degree of rurality. Compared with urban patients, rural dialysis patients were older, less racially diverse with a higher prevalence of most co-morbid conditions. Hemodialysis was the dominant modality in both urban and rural areas, although the use of peritoneal dialysis was more frequent in rural areas. Survival and time to transplant differed by racial-ethnic group. Most notably, despite slightly better survival associated with rural vs urban residence among black populations, black populations living in rural areas were less likely to be transplanted than their urban counterparts (and than any other group examined). Compared with urban facilities, rural facilities are smaller, less likely to be for profit or owned by a large chain. Nonetheless, rural facilities perform at least as well as urban facilities based on standard performance measures. Despite more frequent use of peritoneal dialysis among rural patients, rural facilities were markedly less likely to offer peritoneal dialysis or home hemodialysis training than urban facilities. Rural black patients (most of whom live in the south) should be targeted in policies to reduce racial disparities in access to transplant. Further studies are needed to determine whether rural dialysis patients have adequate access to home-based therapies.