Peritoneal dialysis: the ideal bridge from conservative therapy to kidney transplant

Effect of Pretransplant Dialysis Method and Vintage on Early Clinical Outcomes of Kidney Transplantation

BACKGROUND

Pre-transplantation dialysis duration and modality may affect patients' long-term (mortality and graft failure) and short-term (delayed graft function) outcomes after kidney transplantation. We aimed to assess the impact of the method and duration of dialysis therapy on the graft function in the first 6 months post-transplant.

METHODS

The analysis included 122 kidney transplant patients (109 from a deceased donor and 13 from a living donor). Before transplantation, 91 were on hemodialysis (HD), 19 were on peritoneal dialysis (PD), and 9 received preemptive transplants. The incidence of delayed graft function (DGF) and creatinine levels at discharge and 6 months after transplantation were assessed.

RESULTS

PD and HD patients did not differ in age, number of mismatches, and cold ischemia time (CIT), but they had a significantly shorter dialysis vintage (18.3 ± 25.7 vs 39.6 ± 34.3 months, P = .01) and a lower incidence of DGF (5% vs 37%, P = .006). The duration of hospitalization and creatinine concentration at discharge and after 6 months were similar. Preemptively transplanted patients had a significantly shorter CIT (ND vs DO - 576 ± 362 vs 1113 ± 574, P = .01; ND vs HD - 576 ± 362 vs 1025 ± 585 minutes, P = .01). DGF did not occur in any of the patients transplanted preemptively. They had slightly shorter hospitalization times and, compared to HD, better graft function at discharge. After 6 months, creatinine levels were comparable to HD and PD. Patients dialyzed for less than 12 months, regardless of the method, had a lower incidence of DGF.

CONCLUSIONS

Peritoneal dialysis and a short duration of pre-transplant dialysis may improve the early results of kidney transplantation.

Epidemiology and Outcomes of Children with Kidney Failure Receiving Kidney Replacement Therapy in Australia and New Zealand

Introduction

The incidence and outcomes of kidney replacement therapy (KRT) have been well-studied in adults, but much less so in children. This study aimed to investigate the epidemiology and outcomes of KRT in children in Australia and New Zealand from 2000 to 2020.

Methods

Children aged <18 years initiating KRT in Australia and New Zealand between January 1, 2000 and December 31, 2020 and reported to the Australia and New Zealand Dialysis and Transplant Registry were included. Patient survival, technique-survival, and graft survival were analyzed by Cox regression analyses.

Results

Overall, 1058 children (median [interquartile range (IQR)] age 11 [5-15] years, 41% female, 66% White) were followed-up with for a median period of 12.3 years. First KRT modalities were peritoneal dialysis (PD; 48%), hemodialysis (HD; 34%), and kidney transplantation (KT; 18%). Pre-emptive KT incidence was highest in Caucasian children (80.4%) and lowest in the Indigenous population (3.2%). There was no difference in 5-year patient survival rates between 2011 and 2020 (96.9%, 95% confidence interval [CI] 93.8-98.4) and the preceding decade, 2000-2010 (94.5%, 95% CI 90.4-96.8) (P = 0.79). There was no difference in 5-year death-censored technique survival between 2011 and 2020 (51.2%, 95% CI 39.1-62) and 2000-2010 (48.8%, 95% CI 40.5-56.6) (P = 0.27). However, 5-year derath-censored graft survival was significantly higher in 2011-2020 (88.4%, 95% CI 84.6-91.4) than in 2000-2010 (84.3%, 95% CI 80.4-87.5) (P < 0.001).

Conclusions

PD is the most commonly prescribed KRT modality for children in Australia and New Zealand. Patient-survival, technique-survival, and graft survival rates are excellent and graft survival has improved over the last 2 decades.

Reasons for kidney transplant refusal among patients receiving peritoneal dialysis: A qualitative study

BACKGROUND

Even though kidney transplantation has better outcomes compared to dialysis therapies, some patients undergoing peritoneal dialysis (PD) refuse to consider kidney transplantation. Identification of the underlying reason for patient refusal may improve patients' acceptance of kidney transplantation.

AIM

The aim of this study was to describe the reasons given by Iranian PD patients for refusing kidney transplantation.

METHOD

Eighteen patients undergoing PD participated. Data were collected using semi-structured interviews and were analysed using conventional qualitative content analysis.

RESULTS

The analysis leads to the emergence of two categories and six subcategories: negative outcomes of kidney transplantation (financial burden, psychosocial problems and physical complications) and doubtful factors for kidney transplantation (negative attitudes towards kidney transplantation, long waiting time for kidney transplantation and compatibility of PD with daily life). The financial burden and long waiting time for kidney transplantation were the most important factors in the reluctance of kidney transplantation by PD patients.

IMPLICATION FOR PRACTICE

Patients undergoing PD declined kidney transplantation for several reasons, such as financial burden, fear of post-transplantation side effects, long waiting time for kidney transplantation. Reducing the time of kidney transplantation and insurance coverage of transplant costs can change the attitude of PD patients towards transplant.

Choice of the Dialysis Modality: Practical Considerations

Chronic kidney disease and the need for kidney replacement therapy have increased dramatically in recent decades. Forecasts for the coming years predict an even greater increase, especially in low- and middle-income countries, due to the rise in metabolic and cardiovascular diseases and the aging population. Access to kidney replacement treatments may not be available to all patients, making it especially strategic to set up therapy programs that can ensure the best possible treatment for the greatest number of patients. The choice of the "ideal" kidney replacement therapy often conflicts with medical availability and the patient's tolerance. This paper discusses the pros and cons of various kidney replacement therapy options and their real-world applicability limits.

Intensification of Middle- and High-Molecular-Weight Toxins Removal in Dialysis Process

A novel extracorporeal circuit for hemodialysis is described, which enhances the removal of middle- and high-molecular-weight toxins. To enhance the removal of especially high-molecular toxins, a recirculation pathway for dialysate flow is added to conventional circuit. The influence of an increase in the ratio of recirculation to dialysate flow rate and the ultrafiltration rate (UFR) on the removal of toxins was investigated to evaluate the removal of different toxins in clinical conditions. Removal of toxins was also modeled by an analytical method and solved by the MATLAB software (The MathWorks, Inc., Natick, MA). A significant increase in removal of urea (up to 31%) and vitamin B12 (11%) was achieved when the UFR is low (≤50 ml/h) or zero. The model showed an excellent agreement with the experimental results, which indicates its applicability for the removal of different toxins in an extracorporeal circuit. Increase in recirculation flow, while adjusting the UFR near zero, improves the mass transfer coefficient and can lead to enhanced especially middle- and high-molecular-weight toxin removal.

Peritoneal Dialysis for Potential Kidney Transplant Recipients: Pride or Prejudice?

Kidney transplantation (KT) is recognized as the gold-standard of treatment for patients with end-stage renal disease. Additionally, it has been demonstrated that receiving a pre-emptive KT ensures the best recipient and graft survivals. However, due to an overwhelming discrepancy between the organs available and the patients on the transplant waiting list, the vast majority of transplant candidates require prolonged periods of dialysis before being transplanted. For many years, peritoneal dialysis (PD) and hemodialysis (HD) have been considered competitive renal replacement therapies (RRT). This dualistic vision has recently been questioned by evidence suggesting that an individualized and flexible approach may be more appropriate. In fact, tailored and cleverly planned changes between different RRT modalities, according to the patient’s needs and characteristics, are often needed in order to achieve the best results. While home HD is still under scrutiny in this particular setting, current data seems to favor the use of PD over in-center HD in patients awaiting a KT. In this specific population, the demonstrated advantages of PD are superior quality of life, longer preservation of residual renal function, lower incidence of delayed graft function, better recipient survival, and reduced cost.

Peritoneal Dialysis Failure and its Impact on Holistic Kidney Care: A Case Report

Introduction

Peritonitis remains the primary cause of treatment failure among patients with end-stage kidney disease on continuous ambulatory peritoneal dialysis. However, detailed case analyses illustrating the application of current research in clinical practice remain scant. This case report aimed to elucidate the roles of dialysis nurses in a hospital setting in the management of a 62-year-old male patient with a history of kidney failure secondary to amyloidosis.

Case Presentation

The patient was diagnosed with continuous ambulatory peritoneal dialysis-associated peritonitis.

Management and Outcomes

Dialysis nurses applied evidence-based practices in the management of the patient’s exit-site infection, imbalanced nutrition, and psychosocial concerns. The patient was discharged after 7 days, with a comprehensive treatment regimen, including an individualized peritoneal dialysis protocol adjusted to his daily schedules, education on self-care techniques, and continual nutritional management to prevent recurrence and improve his overall health. This case report shows that admissions for continuous ambulatory peritoneal dialysis-associated peritonitis require evidence-based nursing interventions specific to, and geared toward, each patient’s prioritized health problems.

Discussion

Peritonitis cases are preventable with appropriate nursing interventions that can lower the chance of treatment failure and long-term impact caused by an abrupt switch to hemodialysis. To successfully manage patients with continuous ambulatory peritoneal dialysis-associated peritonitis, dialysis nurses should appreciate the intricacies of the analyses underpinning their professional practices in promoting the patient’s self-care techniques.

Spectrum of Complications of Patients with Chronic Kidney Disease on Maintenance Continuous Ambulatory Peritoneal Dialysis: An Experience of Tertiary Nephrology Center in Najaf City-Iraq

BACKGROUND: Chronic kidney disease (CKD), also called chronic kidney failure, is described as gradual loss of kidney function. CKD can progress to end-stage kidney failure, which is fatal without artificial filtering (dialysis) or kidney transplant. Peritoneal dialysis (PD) has a widespread renal replacement therapy with great acceptance because of simplicity, flexibility, and independence. AIM: The aim of this study was to evaluate the complications of continuous ambulatory PD (CAPD) in patients with CKD. METHODS: A cross-sectional study, involved 140 patients, aged between 18 and 80 years old and suffered from CKD under maintenance CAPD in the dialysis unit of the renal center. All data regarding the sociodemographic profile of the patient, vitals, etiological diagnosis, frequency and duration of dialysis, and dialysis-related complications were taken. RESULTS: In the current study, there is a significant difference in the distribution of complications among gender where the female patients had a higher incidence of both infectious and non-infectious complications. The study also reported that there is much lower rate of complications among patients on laparoscope operation in compared with the open operation. In addition, patients with open abdomen PD developed the complications earlier than those with laparoscope maintenance CAPD. CONCLUSION: Peritoneal infection is the most prevalent complication among the other complications in the current study. There is much lower rate of complications among patients on PD in compared with hemodialysis and on laparoscope in compared with the open operation.

Returning to PD after kidney transplant failure is a valuable option

PURPOSE

There is a paucity of data on the prognosis for patients returning to peritoneal dialysis (PD) after a failed transplant. PD has an advantage over hemodialysis in preserving residual renal function, which is associated with better outcomes.

METHODS

We have reviewed the electronic charts of patients on PD in a tertiary academic hospital for the last 8 years. We have compared technique survival, peritonitis-free survival, and residual diuresis in two groups: patients with graft failure which returned to PD (PD-KTx, N = 18) and patients starting PD for other causes (PD-not KTx, N = 163).

RESULTS

The median follow-up was similar between groups [42(16,71) in PD-not KTx vs. 48(22,90) months in PD-KTx, p = 0.293]. Kaplan-Meier survival comparing PD-KTx and PD-not KTx showed no difference in technique survival (p = 0.196), and peritonitis-free survival (log-rank 0.238), which were confirmed in a fully adjusted Cox regression. Diuresis at baseline and at the end of the first year was similar between groups (p = 0.799 and p = 0.354, respectively). Six out of 18 patients from the PD-KTx group had the immunosuppression maintained and none of those had peritonitis. The reduction of diuresis across the first year of PD was significant for all patients, except for those on continued immunosuppressive therapy.

CONCLUSION

PD is a worthy dialysis alternative after a failed kidney transplant, providing similar outcomes when compared to patients who started PD for other reasons.