Racial and social disparities in the access to automated peritoneal dialysis - results of a national PD cohort

A randomized controlled trial to evaluate and assess the effect of comprehensive pre-end stage kidney disease education on home dialysis use in veterans, rationale and design

BACKGROUND

Informed dialysis selection and greater home dialysis use are the two long-desired, underachieved targets of advanced chronic kidney disease (CKD) care in the US healthcare system. Observational institutional studies have shown that comprehensive pre-kidney failure, conventionally referred to as end stage kidney disease education (CPE) can improve both these outcomes. However, lack of validated protocols, well-controlled studies, and systemic models have limited wide-spread adoption of CPE in the US. We hypothesized that a universal CPE and patient-centered initiation of kidney replacement therapy can improve multiple clinical, patient-centered and health service outcomes in advanced CKD and kidney failure requiring dialysis therapy.

METHODS

Trial to Evaluate and Assess the effects of CPE on Home dialysis in Veterans (TEACH-VET) is a multi-method randomized controlled trial aimed to evaluate the effects of a system-based approach for providing CPE to all Veterans with advanced CKD across a regional healthcare System. The study will randomize 544 Veterans with non-dialysis stage 4 and 5 CKD in a 1:1 allocation stratified by their annual family income and the stage of CKD to an intervention (CPE) arm or control arm. Intervention arm will receive a two-phase CPE in an intent-to-teach manner. Control arm will receive usual clinical care supplemented by resources for the freely-available kidney disease information. Participants will be followed after intervention/control for the duration of the study or until 90-days post-kidney failure, whichever occurs earlier.

RESULTS

The primary outcome will assess the proportion of Veterans using home dialysis at 90-days post-kidney failure, and secondary outcomes will include post-intervention/control CKD knowledge, confidence in dialysis decision and home dialysis selection. Qualitative arm of the study will use semi-structured interviews to in-depth assess Veterans' satisfaction with the intervention, preference for delivery, and barriers and facilitators to home dialysis selection and use. Several post-kidney failure clinical, patient-centered and health services outcomes will be assessed 90-days post-kidney failure as additional secondary outcomes.

CONCLUSION

The results will provide evidence regarding the need and efficacy of a system-based, patient-centered approach towards universal CPE for all patients with advanced CKD. If successful, this may provide a blueprint for developing such programs across the similar healthcare infrastructures throughout the country.

TRIAL REGISTRATION

NCT04064086 .

Clinical and dialysis outcomes of manual chronic peritoneal dialysis in low-body-weight children from a low-to-middle-income country

BACKGROUND

Peritoneal dialysis (PD) is the preferred modality of renal replacement therapy in children with end-stage renal disease (ESRD). In developing countries, the challenges of initiating and sustaining chronic peritoneal dialysis (CPD) are many and are not well-described in the literature.

METHODS

This was a retrospective study of children aged 0-18 years on manual PD. The objective was to compare the clinical (growth) and dialysis outcomes (dialysis adequacy and peritonitis rates) in young children with low body weight (LBW; ≤15 kg) on CPD with children weighing >15 kg.

RESULTS

We found that at baseline, the dialysis prescription, sociodemographic parameters, and the prevalence of complications of ESRD were similar in both groups. On follow-up, however, growth was significantly more affected in LBW children than the rest of the cohort. The adequacy of dialysis and peritonitis rates were comparable between groups.

CONCLUSIONS

Despite all the challenges, manual CPD is a feasible modality of dialysis in young children with LBW, and their outcomes are comparable to older children even in low-to-middle-income countries. Appropriate early management of associated complications and improving dialysis adequacy are necessary to improve the outcomes in these children.

APD or CAPD: one glove does not fit all

The use of Automated Peritoneal Dialysis (APD) in its various forms has increased over the past few years mainly in developed countries. This could be attributed to improved cycler design, apparent lifestyle benefits and the ability to achieve adequacy and ultrafiltration targets. However, the dilemma of choosing the superior modality between APD and Continuous Ambulatory Peritoneal Dialysis (CAPD) has not yet been resolved. When it comes to fast transporters and assisted PD, APD is certainly considered the most suitable Peritoneal Dialysis (PD) modality. Improved patients’ compliance, lower intraperitoneal pressure and possibly lower incidence of peritonitis have been also associated with APD. However, concerns regarding increased cost, a more rapid decline in residual renal function, inadequate sodium removal and disturbed sleep are APD’s setbacks. Besides APD superiority over CAPD in fast transporters, the other medical advantages of APD still remain controversial. In any case, APD should be readily available for all patients starting PD and the most important indication for its implementation remains patient’s choice.

Clinical utility of a traditional score system for the evaluation of the peritoneal dialysis exit-site infection in a national multicentric cohort study

INTRODUCTION

Exit-site infection (ESI) is an important risk factor for peritonitis in patients under chronic peritoneal dialysis (PD). The International Society for Peritoneal Dialysis (ISPD) recommend its diagnosis as the presence of purulent drainage in the exit site (ES) but time-consuming scores using others skin signs are routinely used.

OBJECTIVE

To investigate the correlation between the diagnosis of ESI with a score based on five clinical signs obtained from ES inspection, and also if there are interaction with patient's race.

METHODS

Multicenter and prospective cohort. We included adult patients from 122 clinics, incident on PD and with a 12-month stay in therapy. The event of interest was ESI, defined as purulent drainage. The clinical score used was composed of hyperemia, edema, pain, scab, and granuloma. Statistical analysis was performed using multilevel logistic regression model, likelihood test, and Cohen concordance analysis.

RESULTS

A total of 35,354 ES assessments were performed during the first year of dialysis in 3297 patients. There was a rate of 10.1 (9.1-11.2) episodes of ESI per 1000 patients/month. In patients with ESI, the prevalence of hyperemia was 55.9%, edema 67.3%, pain 31.8%, and scab 23.2%. The agreement with the score was 60.6% and showed differences according to the patient's race, being 53.2% for African Americans descendants and 65.4% for others. The use of scales for the diagnosis of ESI does not add much information in addition to the presence of purulent secretion as currently recommended by the ISPD.