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Background and Objectives: The 1999 Canadian vascular access guidelines recommend the fistula as the access of choice. The study describes the trends in hemodialysis access use, variation among provinces, and the association with mortality from 2001 to 2004., Design, Setting, Participants and Measurements: An observational study of adult patients registered in Canadian Organ Replacement Registry on hemodialysis. Access trends were examined among incident and prevalent hemodialysis patients adjusted for age, sex, body mass index, late referral, race, smoking status, province, etiology of end-stage renal disease, and comorbidities. Cox proportional hazard regression analysis was used to analyze risk for death for patients followed to December 31, 2005., Results: From 2001 to 2004, incident catheter use increased from 76.8% to 79.1%, fistulas decreased from 21.6% to 18.6%, and grafts remained between 2.1% to 2.6%. Prevalent catheter use increased from 41.8% to 51.7%, and fistulas and grafts decreased from 46.8% to 41.6% and 11.4% to 6.7%, respectively. There was significant variation in incident and prevalent fistulae use among the provinces. Adjustment for differences in patient characteristics did not change these trends. Incident catheter use was associated with a 6 times greater risk of death compared with fistula or graft use combined., Conclusions: In Canada there has been a decrease in fistulae and grafts with a subsequent increase in catheters that is not explained by changes in patient characteristics. Vascular access use varied by province, suggesting differences in practice patterns. Because incident catheter use was associated with increased mortality, urgent measures are needed to develop strategies to decrease catheter use.

Aims: To determine if rates of diabetic and non-diabetic end-stage renal disease (ESRD), which had been rising in young and middle-aged adults in all populations up to the mid-1990s, had started to decline, and if so, whether improvement had occurred in respect of each of the principal primary renal diseases causing ESRD., Methods: Poisson regression of age- and sex-standardized incidence of ESRD for persons aged 20-64 years in 18 populations from Europe, Canada and the Asia-Pacific region, for 1998-2002., Results: In persons from 12 European descent (Europid) populations combined, there was a small downward trend in all-cause ESRD (-1.7% per year, P = 0.001), with type 1 diabetic ESRD falling by 7.8% per year (P < 0.001), glomerulonephritic ESRD by 3.1% per year (P = 0.001), and 'all other non-diabetic' ESRD by 2.5% per year (P = 0.02). The reductions in ESRD attributed to hypertensive (-2.2% per year) and polycystic renal disease (-1.5% per year) and unknown diagnosis (-0.2% per year) were not statistically significant. On the other hand, the incidence of type 2 diabetic ESRD rose by 9.9% per year (P < 0.001) in the combined Europid population, although that of (principally type 2) diabetic ESRD remained unchanged in the pooled data from the four non-Europid populations., Conclusion: Recent preventive strategies, probably chiefly modern renoprotective treatment, appear to have been effective for tertiary prevention of ESRD caused by the proteinuric nephropathies other than type 2 diabetic nephropathy, for which the continuing increase in Europid populations represents a failure of prevention and/or a change in the nephropathic potential of type 2 diabetes.

Data from the Canadian Organ Replacement Registry (CORR) and the Dialysis Outcomes and Practice Patterns Study (DOPPS) were used to determine whether practice patterns have changed in Canada since the introduction of the Canadian Society of Nephrology (CSN) Guidelines in 1999. DOPPS data were then used to calculate the impact of not meeting the proposed guideline targets and to estimate the potential life years gained if all Canadian hemodialysis patients achieved guideline targets. For dialysis dose and hemoglobin targets, Canadian facility performance has significantly improved over time. The vascular access use patterns show trends toward a worse pattern with increased catheter use. A calculation of the percentage of attributable risk suggests that 49% of deaths could possibly be averted if all patients currently outside the guidelines achieved them over the next five years. This corresponds to a decrease in the annual death rate from 18 to 10.1 per hundred patient years. These data support the need for improved adherence to guidelines. If Canadian caregivers were to optimize practice patterns, patient outcomes could be improved.

End-stage renal disease is a significant complication of heart transplantation (HTx), but our understanding of dialysis outcomes in HTx recipients remains limited. We performed a retrospective analysis looking at dialysis mortality in HTx recipients as compared to a matched dialysis cohort. We also examined outcomes with respect to kidney transplantation (KTx) in these cohorts. 2709 incident HTx recipients were captured from the Canadian Organ Replacement Register between 1981 and 2002. The incidence of dialysis after HTx was 3.9% (n = 105) and carried a greater crude mortality compared to HTx recipients not requiring dialysis (56.2% vs. 35.9%, p < 0.001). Compared to the matched dialysis cohort, survival of HTx patients on dialysis was also significantly worse (19% vs. 40%, p = 0.003). In those receiving a KTx, survival did not differ between the two cohorts; however, in those that did not receive a KTx the survival was significantly lower in the dialysis post-HTx group compared to the matched dialysis cohort (15.7% vs. 35.2%, p < 0.025). Our analysis suggests mortality on dialysis following HTx is greater than would be expected from a similar dialysis population, and KTx may abrogate some of this increased risk. Attention should be placed on preventing chronic kidney disease progression following HTx.

Background: Despite improved treatment of hypertension and decreasing rates of stroke and coronary heart disease, the reported incidence of hypertensive end-stage renal disease (ESRD) increased during the 1990s. However, bias, particularly from variations in acceptance into ESRD treatment (ascertainment) and diagnosis (classification), has been a major source of error when comparing ESRD incidences or estimating trends., Methods: Age-standardized rates were calculated in persons aged 30 to 44, 45 to 64, and 65 to 74 years for 15 countries or regions (separately for the Europid and non-Europid populations of Canada, Australia, and New Zealand), and temporal trends were estimated by means of Poisson regression. For 10 countries or regions, population-based estimates of mean systolic blood pressures and prevalences of hypertension were extracted from published sources., Results: Hypertensive ESRD, comprising ESRD attributed to essential hypertension or renal artery occlusion, was least common in Finland, non-Aboriginal Australians, and non-Polynesian New Zealanders; intermediate in most European and Canadian populations; and most common in Aboriginal Australians and New Zealand Maori and Pacific Island people. Rates correlated with the incidence of all other nondiabetic ESRD, but not with diabetic ESRD or community rates of hypertension. Between 1998 and 2002, hypertensive ESRD did not increase in Northwestern Europe or non-Aboriginal Canadians, although it did so in Australia., Conclusion: Despite the likelihood of classification bias, the probability remains of significant variation in incidence of hypertensive ESRD within the group of Europid populations. These between-population differences are not explained by community rates of hypertension or ascertainment bias.