tion’, implying that most patients ‘should’ receive a particular action. In contrast, level 2 guidelines are essentially ‘suggestions’ and are deemed to be ‘weak’ or discretionary, recognising that management decisions may vary in different clinical contexts. Each recommendation was further graded from A to D by the quality of evidence underpinning them, with grade A referring to a high quality of evidence whilst grade D recognised a ‘very low’ evidence base. The overall strength and quality of the supporting evidence is summarised in table 1 . The guidelines focused on 4 key domains: (1) AKI definition, (2) prevention and treatment of AKI, (3) contrastinduced AKI (CI-AKI) and (4) dialysis interventions for the treatment of AKI. The full summary of clinical practice statements is available at www.kdigo.org, but a few key recommendation statements will be highlighted here.

/pdf/kdigo-clinical-practice-guidelines-for-acute-kidney-injury-27tybolw7l.pdf

KDIGO clinical practice guidelines for acute kidney injury.

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(13)60687-X.pdf

Chronic kidney disease: global dimension and perspectives

https://www.emcdda.europa.eu/attachements.cfm/att_231442_EN_INT17_easl-recommendations-on-treatment-of-hepatitis-C.pdf

EASL Recommendations on Treatment of Hepatitis C

https://minerva-access.unimelb.edu.au/bitstream/handle/11343/238777/Global, regional, and national burden of chronic kidney.pdf

Global, regional, and national burden of chronic kidney disease, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017

https://www.natap.org/2007/HIV/PIIS0140673607610502.pdf

Incidence of cancers in people with HIV/AIDS compared with immunosuppressed transplant recipients: a meta-analysis

ContextImmune suppression after organ transplantation is associated with a markedly increased risk of nonmelanoma skin cancer and a few virus-associated cancers. Although it is generally accepted that other cancers do not occur at increased rates, there have been few long-term population-based cohort studies performed.ObjectiveTo compare the incidence of cancer in patients receiving immune suppression after kidney transplantation with incidence in the same population in 2 periods before receipt of immune suppression: during dialysis and during end-stage kidney disease before renal replacement therapy (RRT).Design, Setting, and ParticipantsA population-based cohort study of 28 855 patients with end-stage kidney disease who received RRT, with 273 407 person-years of follow-up. Incident cancers (1982-2003) were ascertained by record linkage between the Australia and New Zealand Dialysis and Transplant Registry and the Australian National Cancer Statistics Clearing House.Main Outcome MeasureStandardized incidence ratios (SIRs) of cancer, using age-specific, sex-specific, calendar year–specific, and state/territory–specific population cancer incidence rates.ResultsThe overall incidence of cancer, excluding nonmelanoma skin cancer and those cancers known to frequently cause end-stage kidney disease, was markedly increased after transplantation (n = 1236; SIR, 3.27; 95% confidence interval [CI], 3.09-3.46). In contrast, cancer incidence was only slightly increased during dialysis (n = 870; SIR, 1.35; 95% CI, 1.27-1.45) and before RRT (n = 689; SIR, 1.16; 95% CI, 1.08-1.25). After transplantation, cancer occurred at significantly increased incidence at 25 sites, and risk exceeded 3-fold at 18 of these sites. Most of these cancers were of known or suspected viral etiology.ConclusionsKidney transplantation is associated with a marked increase in cancer risk at a wide variety of sites. Because SIRs for most types of cancer were not increased before transplantation, immune suppression may be responsible for the increased risk. These data suggest a broader than previously appreciated role of the interaction between the immune system and common viral infections in the etiology of cancer.

https://jamanetwork.com/journals/jama/articlepdf/204654/joc60169_2823_2831.pdf

Cancer Incidence Before and After Kidney Transplantation

BACKGROUND Although renal-replacement therapy for children with end-stage renal disease has been used for several decades, data on patients' long-term survival are sparse. METHODS We examined the long-term survival of all children and adolescents who were under 20 years of age when renal-replacement therapy commenced (study period, April 1963 through March 2002), using data from the Australia and New Zealand Dialysis and Transplant Registry. Survival was analyzed with the use of Kaplan-Meier methods and age-standardized mortality rates. Risk factors for death were analyzed with the use of Cox regression analysis with time-dependent covariates. RESULTS A total of 1634 children and adolescents were followed for a median of 9.7 years. The long-term survival rate among children requiring renal-replacement therapy was 79 percent at 10 years and 66 percent at 20 years. Mortality rates were 30 times as high as for children without end-stage renal disease. Risk factors for death were a young age at the time renal-replacement therapy was initiated (especially for children under 1 year of age, among whom the risk was four times as high as for children 15 to 19 years of age) and treatment with dialysis (which was associated with a risk more than four times as high as for renal transplantation). Overall, a trend toward improved survival was observed over the four decades of the study. CONCLUSIONS Despite improvement in long-term survival, mortality rates among children requiring renal-replacement therapy remain substantially higher than those among children without end-stage renal disease. Increasing the proportion of children treated with renal transplantation rather than with dialysis can improve survival further.

https://www.nejm.org/doi/pdf/10.1056/NEJMoa031643

Long-Term Survival of Children with End-Stage Renal Disease

The native arteriovenous fistula (AVF) is the preferred vascular access because of its longevity and its lower rates of infection and intervention. Recent studies suggest that the AVF may offer a survival advantage. Because these data were derived from observational studies, they are prone to potential bias. The use of propensity scores offers an additional method to reduce bias resulting from nonrandomized treatment assignment. Adult (age 18 yr or more) patients who commenced hemodialysis in Australia and New Zealand on April 1, 1999, until March 31, 2002, were studied by using the Australian and New Zealand Dialysis and Transplant Association (ANZDATA) Registry. Cox regression was used to determine the effect of access type on total mortality. Propensity scores were calculated and used both as a controlling variable in the multivariable model and to construct matched cohorts. The catheter analysis was stratified by dialysis duration at entry to ANZDATA to satisfy the proportional-hazard assumption. There were 612 deaths in 3749 patients (median follow-up, 1.07 yr). After adjustment for confounding factors and propensity scores, catheter use was predictive of mortality. Patients with arteriovenous grafts (AVG) also had a significantly increased risk of death. Effect estimates were also consistent in the smaller propensity score-matched cohorts. Both AVG and catheter use in incident hemodialysis patients are associated with significant excess of total mortality. Reducing catheter use and increasing the proportion of patients commencing hemodialysis with a mature AVF remain important clinical objectives.

/pdf/vascular-access-and-all-cause-mortality-a-propensity-score-1g78yoawhm.pdf

Vascular Access and All-Cause Mortality: A Propensity Score Analysis

Mortality differences between peritoneal dialysis (PD) and hemodialysis (HD) are widely debated. In this study, mortality was compared between patients treated with PD and HD (including home HD) using data from 27,015 patients in the Australia and New Zealand Dialysis and Transplant Registry, 25,287 of whom were still receiving PD or HD 90 d after entry into the registry. Overall mortality rates were significantly lower during the 90- to 365-d period among those being treated with PD at day 90 (adjusted hazard ratio [HR] 0.89; 95% confidence interval [CI] 0.81 to 0.99]; P < 0.001). This effect, however, varied in direction and size with the presence of comorbidities: Younger patients without comorbidities had a mortality advantage with PD treatment, but other groups did not. After 12 mo, the use of PD at day 90 was associated with significantly increased mortality (adjusted HR 1.33; 95% CI 1.24 to 1.42; P < 0.001). In a supplementary as-treated analysis, PD treatment was associated with lower mortality during the first 90 d (adjusted HR 0.67; 95% CI 0.56 to 0.81; P < 0.001). These data suggest that the effect of dialysis modality on survival for an individual depends on time, age, and presence of comorbidities. Treatment with PD may be advantageous initially but may be associated with higher mortality after 12 mo.

Relationship between Dialysis Modality and Mortality

https://www.kisupplements.org/article/S2157-1716(15)32106-7/pdf

Stephen P. McDonald

Papers

Cancer Incidence Before and After Kidney Transplantation

Long-Term Survival of Children with End-Stage Renal Disease

Vascular Access and All-Cause Mortality: A Propensity Score Analysis

Relationship between Dialysis Modality and Mortality

Australia and New Zealand Dialysis and Transplant Registry