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      Baseline characteristics of an incident haemodialysis population in Spain: results from ANSWER—a multicentre, prospective, observational cohort study

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          Abstract

          Background. The ANSWER study aims to identify risk factors leading to increased cardiovascular morbidity and mortality in a Spanish incident haemodialysis population. This paper summarizes the baseline characteristics of this population.

          Methods. A prospective, observational, one-cohort study, including all consecutive incident haemodialysis patients from 147 Spanish nephrology services, was conducted. Patients were enrolled between October 2003 and September 2004. Sociodemographic, clinical, laboratory and health care characteristics were collected.

          Results. Baseline characteristics are described for 2341 incident haemodialysis patients [mean (SD) age 65.2 (14.5) years, 63% males]. The main cause of renal failure was diabetic nephropathy (26%). The majority of patients (57%) had a Karnofsky score of 80–100 and 27% were followed up by a nephrologist for ≤6 months. In total, 86% of the patients had hypertension, 43% had dyslipidaemia and 44% had a history of cardiovascular disease. Initial vascular access was obtained via a temporary catheter in 30% of patients, via a permanent catheter in 16% and via an arteriovenous fistula in 54%. Albumin levels were <3.5 g/dl in 43% of patients. Immediately prior to the onset of haemodialysis, the mean (SD) glomerular filtration rate (GFR) was 7.6 (2.8) ml/min/1.73 m 2, and only 6.7% of the patients were within the K/DOQI guidelines for all four bone mineral markers. In addition, a high proportion of patients had anaemia markers outside the EBPG guidelines (haemoglobin <11 g/dl, 59%, ferritin <100 or >500 ng/ml, 41% and saturated transferrin <20 or >40%, 50%) despite previous treatment with erythropoiesis-stimulating agents in 41% of cases.

          Conclusions. There is excessive use of temporary catheters and a high prevalence of uraemia-related cardiovascular risk factors among incident haemodialysis patients in Spain. The poor control of hypertension, anaemia, malnutrition and mineral metabolism and late referral to a nephrologist indicate the need for improving the therapeutic management of patients before the onset of haemodialysis.

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          Most cited references54

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          Vitamin D levels and early mortality among incident hemodialysis patients.

          Vitamin D deficiency is associated with cardiovascular disease, the most common cause of mortality in hemodialysis patients. To investigate the relation between blood levels of 25-hydroxyvitamin D (25D) and 1,25-dihydroxyvitamin D (1,25D) with hemodialysis outcomes, we measured baseline vitamin D levels in a cross-sectional analysis of 825 consecutive patients from within a prospective cohort of incident US hemodialysis patients. Of these patients, 78% were considered vitamin D deficient with 18% considered severely deficient. Calcium, phosphorus, and parathyroid hormone levels correlated poorly with 25D and 1,25D concentrations. To test the association between baseline vitamin D levels and 90-day mortality, we selected the next 175 consecutive participants who died within 90 days and compared them to the 750 patients who survived in a nested case-control analysis. While low vitamin D levels were associated with increased mortality, significant interaction was noted between vitamin D levels, subsequent active vitamin D therapy, and survival. Compared to patients with the highest 25D or 1,25D levels who received therapy, untreated deficient patients were at significantly increased risk for early mortality. Our study shows that among incident hemodialysis patients, vitamin D deficiency is common, correlates poorly with other components of mineral metabolism and is associated with increased early mortality.
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            [The Spanish version of the SF-36 Health Survey (the SF-36 health questionnaire): an instrument for measuring clinical results].

            The present study, performed within the International Quality of Life Assessment project (including researchers from 15 countries) presents preliminary results of the process of adaptation of the SF-36 to be used in Spain. The adaptation was based on the translation/back-translation methodology. Meetings of translators, researchers and patients were organized in order to produce successive versions. A study involving 47 individuals was carried out to assess the relative value (through a visual analogue scale) of each response choice of the questionnaire items. Finally, internal consistency and reproducibility of the Spanish version of the SF-36 was assessed by administering the questionnaire to 46 patients with stable coronary heart disease in two different occasions 2 weeks apart. The average ratings of equivalence of the translated version with the original were high regardless of the difficulty of translation. The rank ordering of mean scores for each responses choice agreed with the ranking assigned in the questionnaire in all cases. Cronbach's Alpha was higher than 0.7 for all dimensions (range: 0.71-0.94) except for Social Functioning scale (alpha = 0.45). Intraclass correlation coefficients between both administrations of the questionnaire ranged from 0.58 to 0.99. The adaptation process of the SF-36 has concluded with an instrument apparently equivalent to the original and with an acceptable level of reliability. Nevertheless, other basic characteristics of the adapted questionnaire (i.e. validity and sensitivity to changes) should be also assessed.
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              End-stage renal disease in the United States: an update from the United States Renal Data System.

              Patients with ESRD consume a vastly disproportionate amount of financial and human resources. Approximately 0.03% of the US population began renal replacement therapy in 2004, an adjusted incidence rate of 339 per million. Declining incidence rates were observed for most primary causes of ESRD and in most major demographic categories; the worry is that rates of diabetic ESRD continue to rise in younger black adults. Although diabetes and hypertension remain the most commonly reported cause of ESRD, rates of end-stage atherosclerotic renovascular disease seem to be on the rise in older patients. Although clinical care indicators, such as the proportion of hemodialysis patients using fistulas, continue to improve gradually, the proportion of patients overshooting target hemoglobin levels under epoetin therapy may be a source of concern. Survival probabilities have improved steadily in the US ESRD population since the late 1980s, which is remarkable when one considers the ever-expanding burden of comorbidity in incident patients. However, although first-year dialysis mortality rates have clearly improved since 1987, meaningful improvements do not seem to have accrued since 1993, in contrast to steady annual improvements in years 2 through 5. Although most of these findings are grounds for cautious optimism, the same cannot be said for issues of cost; reflecting the growth in the size of the ESRD population, associated costs grew by 57% between 1999 and 2004 and now account for 6.7% of total Medicare expenditures.
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                Author and article information

                Journal
                Nephrol Dial Transplant
                ndt
                ndt
                Nephrology Dialysis Transplantation
                Oxford University Press
                0931-0509
                1460-2385
                February 2009
                21 November 2008
                21 November 2008
                : 24
                : 2
                : 578-588
                Affiliations
                [1 ]Servicio de Nefrologia, Hospital Gregorio Marañón , Madrid
                [2 ]Servicio de Nefrologia, Hospital Reina Sofia , Cordoba
                [3 ]Servicio de Nefrologia, Hospital Vall d’Hebron
                [4 ]Servicio de Nefrologia, Hospital Consorci Sanitari de Terrassa
                [5 ]Amgen S.A., Barcelona
                [6 ]Unidad de Epidemiología Clinica, Hospital Puerta de Hierro , Madrid, Spain
                Author notes
                Correspondence and offprint requests to: Rafael Pérez-García, Servicio de Nefrología, Hospital Gregorio Marañón, C/Doctor Esquerdo, 46-28007 Madrid, Spain. Tel: +34-915-86-80-47; Fax: +34-915-86-83-18; E-mail: rperezgarcia@ 123456senefro.org
                Article
                gfn464
                10.1093/ndt/gfn464
                2639334
                19028750
                f77a8d5d-6d37-4ece-92aa-ad3be3fa4af8
                © The Author [2008].

                The online version of this article has been published under an open access model. Users are entitled to use, reproduce, disseminate, or display the open access version of this article for non-commercial purposes provided that: the original authorship is properly and fully attributed; the Journal and Oxford University Press are attributed as the original place of publication with the correct citation details given; if an article is subsequently reproduced or disseminated not in its entirety but only in part or as a derivative work this must be clearly indicated. For commercial re-use, please contact journals.permissions@oxfordjournals.org

                History
                : 21 December 2007
                : 22 July 2008
                Categories
                Original Article

                Nephrology
                risk factors,haemodialysis,cardiovascular,vascular access,malnutrition
                Nephrology
                risk factors, haemodialysis, cardiovascular, vascular access, malnutrition

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