Chronic Renal Failure in Nottingham and Requirements for Dialysis and Transplant Facilities S. L. DOMBEYs D. SAGAR, British Medical journal, 1975, 2, 484-485

M. S. KNAPP Results


Summary A retrospective study of uraemic patients covering 12 months of 1970 and a prospective survey covering six months in 1973-4 is reported for a population of almost I million. The number of patients requiring regular dialysis treatment or transplantation or both is considered to be 45 per million of population under 65, 39 per million under 60, and 29 per million under 50 years of age.

There were 402 patients with uraemia aged under 65 in the whole of 1970, and 98% of their case notes were examined. Nine hundred and eighteen patients of all ages had uraemia in the six months studied in 1973-4 apart from those already on dialysis, and 95% of the cases were reviewed. One hundred and four patients aged under 65 (table I) had chronic renal failure in the 1970 study and 79 in the six months of the 1973-4 survey. Chronic renal failure occurred at all ages, but the greatest number of cases were between 40 and 80 (table II).

Introduction Treatment of chronic renal failure requires expensive facilities which are still not available to all patients dying of it. To plan these facilities accurately recent information is needed on the number of patients requiring treatment in the area in question. Estimates of the incidence of uraemia can be found in the tables of Pendreigh and colleagues1 and Platt.' These list 17 previous studies, showing a range of 22 to 151 new patients per million population per year. Different methods of collecting data may have affected the accuracy of the results and may account for the variations. Geographical differences may also occur. Farrow and colleagues3 have tried to predict the requirements for the next five years but suggested that further surveys should take place. This is the first survey to be reported from England other than those based on death certification.


i-Combined Results in Nottingham Uraemic Surveys


ii-Age of Patients with Chronic Renal Failure (1973-4) Age

Method The Nottingham hospitals served a population of 701 500 people in 1970 and 731 400 people in 1973. There are several hospitals but only two laboratories. These laboratories process all blood samples from local hospitals and also all those from non-hospital practice. In the first survey biochemistry laboratory cards from 1970 were examined retrospectively in 1971, and all patients aged under 65 and with blood urea of 16-6 mmol/l (100 mg/100 ml) or greater were assessed by examining their case notes. In the second survey from August 1973 to January 1974 the laboratory cards from patients of all ages were examined as soon as possible after the urea estimation had been performed. This allowed a large number of patients to be assessed while they were still in hospital. It was possible to collect more accurate information and avoid the problems of a retrospective survey.

Having extracted information from the case notes patients subdivided into prerenal, acute renal, chronic renal, and postrenal uraemia. This was a clear decision in the majority of patients. There were uncertainties, usually in distinguishing prerenal from acute renal failure. In some cases, owing to insufficient information having been obtained, there was some doubt, but these patients were classified as prerenal. were

City Hospital, Hucknall Road, Nottingham S. L. DOMBEY, M.B., M.R.C.P., Registrar (Now Medical Registrar, General Hospital, Nottingham) D. SAGAR, M.B., CH.B., General Practitioner M. S. KNAPP, M.D., M.R.C.P., Consultant Physician


11-20 21-30 31-40 41-50 51-60 61-65 66-70 71-80 80 plus

1973-4 (6 months)

Cumulative Total

1 5 5 9 18 23 18 23 30 4

1 6 11 20 38 61 79 102 132 136


excludes (1) patients with chronic renal failure who suitable for dialysis or transplantation because of coincident disease, (2) patients who did not die or become dependent on dialysis treatment during the period of the survey, (3) patients whose death was not attributable to renal failure. Table III shows the number of patients who became dialysisdependent, some of whom died because treatment was not available. Thirty two such patients died of uraemia in 1970 and three survived the year on regular haemodialysis. None received a renal transplant. A dialysis/transplant requirement of 35 new cases each year for Nottingham was demonstrated. In the six months of the 1973-4 study six patients died of "treatable" uraemia and 10 were started on regular dialysis or transplanted. Table IV shows these figures converted into the dialysis/ transplant requirements for Nottingham and the number per million of population for different ages. Table V shows the causes of renal failure, under 65, for the two surveys, and also the causes in all ages in the latter study.



were not

*This method will underestimate the prevalence because of undetected performed during the

cases and known cases who do not have a blood urea


31 MAy 1975


TABLE III-Suitability for Dialysisl Transplantation

disease or in detection rate. We consider it is also likely that doctors may not refer some patients to renal units because they are using criteria for referral which were more appropriate when the facilities in that area were restricted. An alternative explanation is that renal unit physicians might, in practice, have stricter criteria for accepting patients than those used by physicians conducting surveys. It is certainly true that if transplantation or hospital dialysis is not available as an option some of the patients classified in this series as "treatable" would become "untreatable." This was because some were unsuitable for regular home dialysis. There were inadequate numbers of kidney donors and insufficient facilities in Nottingham. This was one of the reasons for "treatable" patients dying during the 1970 and 1973-4 surveys. The European Dialysis and Transplant Association9 has shown a progressively increasing number of patients accepted each year in most European countries for dialysis and/or transplantation. It suggests that this is due to the expansion of treatment facilities. In contrast in Sweden, Denmark, and Switzerland the number of new patients treated per year has been at a constant rate for the last few years, suggesting that the needs of these communities are being fully met. The rates for new patients were 42, 35, and 32 per million in these three countries in 1972. This is a similar number to that detected by the United Kingdom "uraemia surveys" for patients under 60 years old. In the United Kingdom 22 new patients per million population started treatment in 1972.9 The current policy of treating the majority of patients by dialysis only is partly the result of a lack of donor kidneys. The current cost of regular dialysis treatment, approaching £5000 per patient in the first year and £2000 per patient in subsequent years, will pose increasing problems, especially in the current economic situation. A strong case can be made for making a determined attempt to treat an increasing proportion of patients by transplantation. This effort would involve health care planning teams and the community as well as doctors working in renal units and those looking after potential kidney donors. Some doctors10 have challenged this approach mainly because of the higher mortality associated with many transplant series than in reported series of dialysis-treated patients. Few comparable groups of patients have been analysed; selection of patients has varied in most published series. When adequate facilities, finances, and donor kidneys are available a choice between the two forms of treatment will be possible. It will then be appropriate to look carefully at available statistics. A rational decision could then be made about the optimum treatment for an individual patient. At the present time this decision is more likely to be taken on the basis of the unavailability of donor kidneys or, in some areas, of inadequate dialysis facilities or the finance to run them.


1970 (12 months) Alive Dead Unsuitable or uncertain


0-10 11-2G 21-30 31-40 41-50 51-60 61-65

1 1 1 7 (3*) 4 5 9 28 (3*)

1 3 2 3 8 11 5

1973-4 (6 months) Alive Dead Unsuitable or uncertain

0 5 (2*) 5 (2*) 6 (1*)

1 1

17 (4*) 15 (1*)




56 (10*)

0 0 0 2 1 1 2

1 0



0 1 0 7


*Patients started on regular dialysis or transplanted during the period of the survey

TABLE IV-Dialysis/ Transplant Needs per Year Age Under 50 Under 60 Under 65


No./million Population

22 29 34

29 39 45

.. .. ..

Averages of the two surveys to the nearest whole number.

TABLE v-Causes of Chronic Renal Failure 1970 Under 65 No. %

Chronic glomerulonephritis Hypertensive renal disease .. Chronic pyelonephritis .. Obstructive uropathy .. .. Diabetic nephropathy .. Analgesic nephropathy .. Uric acid nephropathy .. Hereditary/congenital .. .. Others/uncertain


16 16 19 6 8 4 7 14

13-5 15-4 15-4 18-3 5-8 7-7 3-8 6-6 135

1973-4 Under 65 No. %

1973-4 All ages No. %

19 10 9 7 7 5 2 7

27 15 10 24 10 12 2 7 29


24-1 12-6 11-4 8-9 8-9 6-3

2-5 8-8 16-5

19-9 11.0 7-3 17-6 7-3 90 1-5 5-2 21*3

Detailed information on the other groups will be reported elsewhere.

Discussion Two surveys from Nottingham hospitals are reported, one retrospective and the other largely prospective. The number of patients with chronic renal failure detected shows a striking similarity between the two studies. This suggests that retrospective studies on this topic may satisfactorily predict the situation if carried out as a "uraemia survey." This is supported by the similarity between these results and those obtained by this method, used retrospectively, in other parts of the United Kingdom. Branch et al.4 estimated 39 patients aged under 60 per million population per year in South Wales, Pendreigh et al.1 52 patients aged under 65 per million of population per year in Scotland, and McGeown5 38 patients aged under 60 per million of population per year in Northern Ireland. No comparable surveys have been reported from England to our knowledge, but the information is similar to the prediction of de Wardener6 based on death certification data. In view of the inherent difficulties of using such data this agreement is perhaps

surprising. The results do not correspond with the available information on the number of patients receiving either regular dialysis or transplantation in this country. This reflects a lack of facilities in some areas, such as Nottingham, or a lack of donor kidneys in others. Some regions have reported7 8 that referral rates to their renal units for dialysis/transplant treatment are smaller than would be predicted by uraemia surveys. This difference might reflect geographical differences in the incidence of

We would like to thank the gift and endowment fund of the Nottingham and District Hospital Management Comnittee and the Siheffield Regional Board for financial support for this project, also the doctors and hospital record department staff who cooperated with the study and made it possible.

References 1 Pendreigh, D. M., et al., Lancet, 1972, 1, 304. 2 Platt, R., Medical Care, 1973, 11, 199. 3

Farrow, S. C., Fisher, A. J., and Johnson, D. B., British Medical Journal,

1972, 3, 686.

4 Branch, R. A., et al., British Medical_Journal, 1971, 1, 249. 5 McGeown, M. G., Lancet, 1972, 1, 249. 6 de Wardener, H. E., Ethics in Medical Progress, ed. G. E. W. Wolsten-

holme and M. O'Connor, p. 104. London, Churchill, 1966. Oliver, D. O., Recent Developments in Haemodialysis. Romford, Macarthys 1973. 8 MacKensie, J. C., 1974, personal communication. 9 Gurland, H. J., et al., Proceedings of the European Dialysis and Transplant, Association, 1973, 10, 111. 10 de Wardener, H. E., The Times, 19 December 1974. 7

Chronic renal failure in Nottingham and requirements for dialysis and transplantfacilities.

A retrospective study of uraemic patients covering 12 months of 1970 and a prospective survey covering six months in 1973-4 is reported for a populati...
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