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Issue Date
1999-01-01
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Treatment of end-stage renal disease in Iceland 1968-1997Citation
Læknablaðið 1999, 85(1):9-21, 24Abstract
Objective: Renal replacement therapy for end-stage renal disease (ESRD) has been provided in Iceland since 1968 when hemodialysis was begun. Kidney transplantation in Icelandic patients has been performed abroad since 1970 mainly in Copenhagen, Gothenburg and Boston. The purpose of this retrospective study was to determine the changes in incidence, prevalence, and outcome of ESRD treatment during the period 1968-1997 and compare the results with other ESRD programs, mainly in the Nordic countries. Material and methods: Included in this study were all patients who began renal replacement therapy for ESRD during the study period and remained on therapy for at least six weeks. Data were obtained from the registry of ESRD, compiled by the Dialysis Service of the National University Hospital. The data were used to determine the annual incidence and prevalence of treated ESRD. Changes in parameters, such as age at the beginning of renal replacement therapy, gender distribution, causes of ESRD, treatment modalities, and survival were evaluated. Annual mortality rate was calculated as deaths per 100 life-years. Comparison of means was done by the two sample t-test, survival was estimated by the Kaplan-Meier method and survival differences were determined with the Mantel-Cox test. Results: A total of 201 patients began therapy for ESRD during this 30 year period. The number of patients beginning renal replacement therapy in each of the three consecutive decades was 27, 59 and 115, respectively, which corresponds to 12.8, 25.1 and 44 per million population per year. The mean age rose throughout the study period and was 54.8 in the final decade. The prevalence per million population was 72 in 1977, 182 in 1987 and 356 in 1997. Diabetic nephropathy was not observed as a cause of ESRD until the last decade when it accounted for 12% of new patients. Hemodialysis was the sole dialysis modality until 1985. Peritoneal dialysis has since provided approximately one third of the dialysis treatment. The number of renal transplants was 13, 30 and 58 for each decade, respectively. At the end of 1997 there were 59 functioning allografts and of these 45 were from living donors. Patients with a functioning allograft were 70% of all ESRD patients at the end of 1997. Allografts came predominantly from cadaveric donors during the first two decades but living donors were 65% in the final decade. The five year survival of transplanted patients (81%) was markedly superior to that of dialyzed patients (16%). The annual mortality rate declined for the whole period, during the last decade it was 10.7 per 100 life-years for all patients, 27.9 for hemodialysis patients, 15.3 for peritoneal dialysis patients and 2.1 for transplanted patients. Death was mainly from cardiovascular causes and infections. Conclusions: There has been marked increase in the incidence and prevalence of treated ESRD in Iceland during the last 30 years. However, the incidence is low compared to the other Nordic countries, mainly as a result of low incidence of ESRD due to glomerulonephritis and diabetic nephropathy. Nearly half the ESRD population has received a renal transplant. Only Norway has a higher prevalence of transplanted patients among the ESRD pool. The percentage of living donor grafts among the transplanted patients is the highest the authors are aware of. Five year patient survival and renal allograft survival in Iceland were comparable to other countries.Inngangur: Hinn 15. ágúst 1968 hófst á Íslandi blóðskilunarmeðferð (hemodialysis) við lokastigsnýrnabilun (end-stage renal disease, ESRD). Fyrsta nýraígræðslan í íslenskan sjúkling fór fram í London 1970 og síðan hafa nýrnaígræðslur ævinlega farið fram erlendis, oftast í Kaupmannahöfn, Gautaborg og Boston. Tilgangur þessarar afturskyggnu rannsóknar var að meta þær breytingar sem orðið hafa á nýgengi, algengi, meðferð og afdrifum sjúklinga 1968-1997 og bera niðurstöður saman við önnur lönd, einkum Norðurlönd. Efniviður og aðferðir: Allir sjúklingar, sem hófu meðferð vegna lokastigsnýrnabilunar á áðurnefndu tímabili og voru í virkri meðferð í að minnsta kosti sex vikur, voru teknir með í rannsóknina. Upplýsingar voru fengnar úr gagnagrunni blóðskilunardeildar Landspítalans. Þær voru notaðar til að meta árlegt nýgengi og algengi meðhöndlaðrar lokastigsnýrnabilunar. Metnar voru breytingar á aldri við upphaf meðferðar, á kynjahlutfalli, grunnsjúkdómum, meðferð og lifun sjúklinga. Árleg dánartíðni var reiknuð sem fjöldi dauðsfalla á 100 lífár. Samanburður meðalgilda var gerður með t-prófi fyrir tvö þýði. Lifun var metin með Kaplan-Meier aðferð og mismunur lifunar með Mantel-Cox aðferð. Niðurstöður: Alls hóf 201 sjúklingur meðferð við lokastigsnýrnabilun á þessu 30 ára tímabili. Fjöldi nýrra sjúklinga í meðferð á hverjum áratugi var 27, 59 og 115 en þær tölur samsvara 12,8, 25,1 og 44 sjúklingum árlega, miðað við milljón íbúa. Meðalaldur við upphaf meðferðar fór hækkandi og var 54,8 ár síðasta tímabilið. Algengi í árslok miðað við milljón íbúa var 72 árið 1977, 182 árið 1987 og 356 árið 1997. Sykursýkinýrnamein kom ekki fram sem orsök lokastigsnýrnabilunar fyrr en á síðasta áratugnum og olli þá 12% tilfella. Blóðskilun var eina skilunarmeðferðin fram til 1985 en kviðskilun (peritoneal dialysis) hefur verið nálægt þriðjungi skilunarmeðferðar síðan. Fjöldi nýrnaígræðslna hvern áratug var 13, 30 og 58. í lok 1997 voru starfandi nýrnagræðlingar 59 og af þeim voru 45 úr lifandi gjöfum. Sjúklingar með ígrædd nýru voru þá 70% allra í meðferð við lokastigsnýrnabilun. Fyrstu tvö tímabilin voru einkum notuð nýru úr nágjöfum (cadaver donors) en nýrum úr lifandi gjöfum fjölgaði mjög á síðasta áratugnum og voru þá 65% græðlinga. Fimm ára lifun ígræddra (81%) var miklu betri en skilunarsjúklinga (16%). Dánartíðni fór lækkandi allt tímabilið. Síðasta áratuginn var hún 10,7 á 100 lífár fyrir allan hópinn, 27,9 meðal sjúklinga í blóðskilun, 15,3 fyrir sjúklinga í kviðskilun og 2,1 hjá ígræddum. Helstu dánarorsakir voru hjarta- og æðasjúkdómar og sýkingar. Ályktanir: Mikil aukning hefur orðið á nýgengi og algengi meðhöndlaðrar lokastigsnýrnabilunar á Islandi á undanförnum 30 árum. Þó er nýgengi mun lægra en á hinum Norðurlöndunum og stafar það af lágu nýgengi lokastigsnýrnabilunar af völdum gauklabólgu og sykursýkinýrnameins hér á landi. Nær helmingur sjúklinganna hefur fengið ígrætt nýra. Noregur einn er með hærra hlutfall ígræddra. Hlutfall nýrnagræðlinga úr lifandi gjöfum meðal ígræddra er það hæsta sem höfundar þekkja. Fimm ára lifun sjúklinga og nýrnagræðlinga á íslandi var sambærileg við það sem gerist meðal nágrannaþjóða.
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