Patient survival among incident peritoneal dialysis and hemodialysis patients in an urban setting

Home dialysis: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

Home dialysis modalities (home hemodialysis [HD] and peritoneal dialysis [PD]) are associated with greater patient autonomy and treatment satisfaction compared with in-center modalities, yet the level of home-dialysis use worldwide is low. Reasons for limited utilization are context-dependent, informed by local resources, dialysis costs, access to healthcare, health system policies, provider bias or preferences, cultural beliefs, individual lifestyle concerns, potential care-partner time, and financial burdens. In May 2021, KDIGO (Kidney Disease: Improving Global Outcomes) convened a controversies conference on home dialysis, focusing on how modality choice and distribution are determined and strategies to expand home-dialysis use. Participants recognized that expanding use of home dialysis within a given health system requires alignment of policy, fiscal resources, organizational structure, provider incentives, and accountability. Clinical outcomes across all dialysis modalities are largely similar, but for specific clinical measures, one modality may have advantages over another. Therefore, choice among available modalities is preference-sensitive, with consideration of quality of life, life goals, clinical characteristics, family or care-partner support, and living environment. Ideally, individuals, their care-partners, and their healthcare teams will employ shared decision-making in assessing initial and subsequent kidney failure treatment options. To meet this goal, iterative, high-quality education and support for healthcare professionals, patients, and care-partners are priorities. Everyone who faces dialysis should have access to home therapy. Facilitating universal access to home dialysis and expanding utilization requires alignment of policy considerations and resources at the dialysis-center level, with clear leadership from informed and motivated clinical teams.

Cancer Screening in End-Stage Kidney Disease

The incidence of cancer is higher in patients with end-stage kidney disease (ESKD) than among the general population. Despite this, screening for cancer is generally not cost-effective and may worsen quality of life in these patients. This is due to high mortality rates (patients are not living long enough to reap the benefits of screening), the inaccuracy of cancer screening tests, and the increased risks associated with therapy in patients with ESKD. Specific groups of patients with ESKD who have a longer-than-expected life expectancy or higher-than-expected cancer risk may benefit from screening. These groups include patients on peritoneal dialysis, patients on home hemodialysis, Black and Asian-American patients, transplant-eligible patients, and those at higher risk of cancer including patients with acquired cystic kidney disease, those who have been previously exposed to cytotoxic agents or aristolochic acid, and patients with a genetic predisposition to cancer. In this narrative review, we will examine the prevalence of and risk factors for cancer in patients with ESKD and the effectiveness of cancer screening, and discuss specific situations in which cancer screening may be effective.

Association of Race with In-Hospital and Post-Hospitalization Mortality in Patients with Acute Kidney Injury

INTRODUCTION

Acute kidney injury (AKI) is known to be associated with increased mortality, and racial differences in hospital mortality exist in patients with AKI. However, it remains to be seen whether racial differences exist in post-hospitalization mortality among AKI patients.

METHODS

We analyzed data of adult AKI patients admitted to the University of Virginia Medical Center between January 1, 2001, and December 31, 2015, to compare in-hospital and post-hospitalization mortality among hospitalized black and white patients with AKI. Multivariable logistic regression analysis was used to analyze the association between race and in-hospital mortality, and 90-day post-hospitalization mortality among AKI patients that were discharged. Kaplan-Meier survival curve was used to evaluate long-term survival between black and white patients.

RESULTS

Black patients had lower in-hospital mortality than white patients after adjusting for age, sex, estimated glomerular filtration rate, hospital length of stay, severity of AKI, comorbidities, and the need for dialysis and mechanical ventilation (odds ratio: 0.82; 95% confidence interval, 0.70-0.96, p = 0.0015). Similarly, at 90-day post-hospitalization, black patients had significantly lower adjusted odds of death than white patients (odds ratio: 0.64; 95% confidence interval, 0.46-0.93; p = 0.008). The median length of follow-up was 11.9 months (0.6-46.7 months). Kaplan-Meier survival curve showed that long-term survival was significantly better in black patients compared to white patients (median duration of survival; 39.7 vs. 24.8 months; p ≤ 0.001).

CONCLUSIONS

Black patients with AKI had lower in-hospital mortality, 90-day post-hospitalization mortality, and better long-term survival rates compared to white patients with AKI.

Peritoneal Dialysis Utilization and Outcome: What are we Facing?

Penetration of peritoneal dialysis (PD) varies tremendously across the world. It ranges from about 80% in Hong Kong and Mexico to just a few percentage points in the United States, Japan, and Germany. While PD is growing in China, India, and some Eastern European and South American countries, it is declining in many European and North American countries. In terms of outcomes, the survival of PD patients is generally comparable to that of hemodialysis (HD) patients and better than that of HD patients during the first few years on dialysis. According to the U.S. Renal Data System, survival of patients on PD has been improving faster than that of patients on HD. In terms of cost, PD is usually cheaper than HD. Hence, declining PD utilization is unjustified. Work is required to identify and overcome negative factors such as physician bias, unfair medical reimbursement systems, and poor patient education.

Arteriovenous access in hemodialysis: A multidisciplinary perspective for future solutions

In hemodialysis, vascular access is a key issue. The preferred access is an arteriovenous fistula on the non-dominant lower arm. If the natural vessels are insufficient for such access, the insertion of a synthetic vascular graft between artery and vein is an option to construct an arteriovenous shunt for punctures. In emergency situations and especially in elderly with narrow and atherosclerotic vessels, a cuffed double-lumen catheter is placed in a larger vein for chronic use. The latter option constitutes a greater risk for infections while arteriovenous fistula and arteriovenous shunt can fail due to stenosis, thrombosis, or infections. This review will recapitulate the vast and interdisciplinary scenario that characterizes hemodialysis vascular access creation and function, since adequate access management must be based on knowledge of the state of the art and on future perspectives. We also discuss recent developments to improve arteriovenous fistula creation and patency, the blood compatibility of arteriovenous shunt, needs to avoid infections, and potential development of tissue engineering applications in hemodialysis vascular access. The ultimate goal is to spread more knowledge in a critical area of medicine that is importantly affecting medical costs of renal replacement therapies and patients’ quality of life.

Peritoneal Dialysis: Better than, Equal to, or Worse than Hemodialysis? Data Worth Knowing before Choosing a Dialysis Modality

Technological advances such as those that allow the delivery of an adequate dialysis dose to a larger percentage of patients, minimization of peritoneal membrane damage with more biocompatible solutions, and lower peritonitis rates will undoubtedly improve retention of patients on peritoneal dialysis (PD) for longer periods. Currently, only 15% of the world dialysis population is managed by PD. Peritoneal dialysis has many advantages over hemodialysis, and if end-stage renal disease (ESRD) patients are fully informed about them, the proportion of patients who would prefer this treatment would rise to 25% – 30%. An integrated approach to the treatment of ESRD could start with PD in a large percentage of patients, especially those who will receive a kidney transplant within 2 – 3 years. With the present epidemic of ESRD, this approach could lead to a significant saving, relieve the pressure on dialysis units, and allow a larger number of ESRD patients to be treated.

The Effect of Technique Failure on Outcome in Black Patients on Continuous Ambulatory Peritoneal Dialysis

Background

We previously reported that, while black patients have a better patient survival than white patients on peritoneal dialysis (PD), they also have a significantly higher technique failure rate (39% vs 8%, p < 0.0001). The purpose of this study was to determine the effect of technique failure/transfer to hemodialysis (HD) on patient survival in black PD patients.

Methods

We retrospectively evaluated 137 incident black patients entering our PD program from January 1987 to December 1997. During the course of follow-up, 82 (60%) patients remained on PD (PD group) while 55 (40%) patients were permanently transferred to HD (PD–HD group). The primary outcome measured was patient survival.

Results

Average age was 49 ± 15 years, 42% were male, and 40% had diabetes mellitus. At baseline, serum creatinine was 10.8 ± 5.4 mg/dL, serum albumin 3.4 ± 0.7 g/dL, body mass index 27.3 ± 6.5 kg/m2, peritoneal transport status was high in 18% and high-average in 61%, and residual glomerular filtration rate was 3.4 ± 3.5 mL/minute. There were no significant differences in clinical features, nutritional status, peritoneal transport, residual renal function, or dialysis adequacy at baseline between the PD group and PD–HD group. While a greater proportion of patients transferring to HD had cardiac disease (53% vs 32%, p < 0.05), there were no other significant differences in 15 comorbid conditions assessed at baseline. The primary reason for transfer was peritonitis (64%) and the overall peritonitis rate in the PD–HD group was significantly higher than in the PD group (2.21 vs 1.17 episodes/patient-year, p < 0.0001). Overall follow-up was 34 ± 25 months for PD group and 44 ± 26 months for PD–HD group ( p < 0.01), with a mean time on PD prior to transfer to HD of 22 ± 18 months. During the course of follow-up, there were no significant differences between the two groups in the number of patients transplanted or deaths. Patient survival at 1, 2, and 5 years was 91%, 80%, and 57% for PD group and 96%, 92%, and 55% for PD–HD group [ p = not significant (NS)]. A risk-adjusted time-dependent Cox regression analysis resulted in an adjusted relative risk of death that was not significantly different for those who transferred from PD to HD versus those who remained on PD (relative risk 1.49; 95% confidence interval 0.77–2.89; p = NS).

Conclusions

In black patients on PD, transfer to HD is not associated with any significant difference in patient survival compared to patients remaining on PD. While a high rate of peritonitis predisposes to technique failure, we found no features at baseline predictive of patients at greatest risk to fail PD. Since technique failure does not portend a poorer prognosis, PD remains a viable option for black patients entering an end-stage renal disease program.

Expanded Prospective Payment System and Use of and Outcomes with Home Dialysis by Race and Ethnicity in the United States

BACKGROUND AND OBJECTIVES

We investigated whether the recent growth in home dialysis use was proportional among all racial/ethnic groups and also whether there were changes in racial/ethnic differences in home dialysis outcomes.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This observational cohort study of US Renal Data System patients initiating dialysis from 2005 to 2013 used logistic regression to estimate racial/ethnic differences in home dialysis initiation over time, and used competing risk models to assess temporal changes in racial/ethnic differences in home dialysis outcomes, specifically: (1) transfer to in-center hemodialysis (HD), (2) mortality, and (3) transplantation.

RESULTS

Of the 523,526 patients initiating dialysis from 2005 to 2013, 55% were white, 28% black, 13% Hispanic, and 4% Asian. In the earliest era (2005-2007), 8.0% of white patients initiated dialysis with home modalities, as did a similar proportion of Asians (9.2%; adjusted odds ratio [aOR], 0.95; 95% confidence interval [95% CI], 0.86 to 1.05), whereas lower proportions of black [5.2%; aOR, 0.71; 95% CI, 0.66 to 0.76] and Hispanic (5.7%; aOR, 0.83; 95% CI, 0.86 to 0.93) patients did so. Over time, home dialysis use increased in all groups and racial/ethnic differences decreased (2011-2013: 10.6% of whites, 8.3% of blacks [aOR, 0.81; 95% CI, 0.77 to 0.85], 9.6% of Hispanics [aOR, 0.94; 95% CI, 0.86 to 1.00], 14.2% of Asians [aOR, 1.04; 95% CI, 0.86 to 1.12]). Compared with white patients, the risk of transferring to in-center HD was higher in blacks, similar in Hispanics, and lower in Asians; these differences remained stable over time. The mortality rate was lower for minority patients than for white patients; this difference increased over time. Transplantation rates were lower for blacks and similar for Hispanics and Asians; over time, the difference in transplantation rates between blacks and Hispanics versus whites increased.

CONCLUSIONS

From 2005 to 2013, as home dialysis use increased, racial/ethnic differences in initiating home dialysis narrowed, without worsening rates of death or transfer to in-center HD in minority patients, as compared with white patients.

Differences in survival on chronic dialysis treatment between ethnic groups in Denmark: a population-wide, national cohort study

BACKGROUND

In Western countries, black and Asian dialysis patients experience better survival compared with white patients. The aim of this study is to compare the survival of native Danish dialysis patients with that of dialysis patients originating from other countries and to explore the association between the duration of residence in Denmark before the start of dialysis and the mortality on dialysis.

METHODS

We performed a population-wide national cohort study of incident chronic dialysis patients in Denmark (≥18 years old) who started dialysis between 1995 and 2010.

RESULTS

In total, 8459 patients were native Danes, 344 originated from other Western countries, 79 from North Africa or West Asia, 173 from South or South-East Asia and 54 from sub-Saharan Africa. Native Danes were more likely to die on dialysis compared with the other groups (crude incidence rates for mortality: 234, 166, 96, 110 and 53 per 1000 person-years, respectively). Native Danes had greater hazard ratios (HRs) for mortality compared with the other groups {HRs for mortality adjusted for sociodemographic and clinical characteristics: 1.32 [95% confidence interval (CI) 1.14-1.54]; 2.22 [95% CI 1.51-3.23]; 1.79 [95% CI 1.41-2.27]; 2.00 [95% CI 1.10-3.57], respectively}. Compared with native Danes, adjusted HRs for mortality for Western immigrants living in Denmark for ≤10 years, >10 to ≤20 years and >20 years were 0.44 (95% CI 0.27-0.71), 0.56 (95% CI 0.39-0.82) and 0.86 (95% CI 0.70-1.04), respectively. For non-Western immigrants, these HRs were 0.42 (95% CI 0.27-0.67), 0.52 (95% CI 0.33-0.80) and 0.48 (95% CI 0.35-0.66), respectively.

CONCLUSIONS

Incident chronic dialysis patients in Denmark originating from countries other than Denmark have a better survival compared with native Danes. For Western immigrants, this survival benefit declines among those who have lived in Denmark longer. For non-Western immigrants, the survival benefit largely remains over time.

Causes for Withdrawal in an Urban Peritoneal Dialysis Program

Background. Peritoneal dialysis (PD) is an underutilized dialysis modality in the United States, especially in urban areas with diverse patient populations. Technique retention is a major concern of dialysis providers and might influence their approach to patients ready to begin dialysis therapy. Methods. Records from January 2009 to March 2014 were abstracted for demographic information, technique duration, and the reasons for withdrawal. Results. The median technique survival of the 128 incident patients during the study window was 781 days (2.1 years). The principle reasons for PD withdrawal were repeated peritonitis (30%); catheter dysfunction (18%); ultrafiltration failure (16%); patient choice or lack of support (16%); or hernia, leak, or other surgical complications (6%); and a total of 6 patients died during this period. Of the patients who did not expire and were not transplanted, most transferred to in-center hemodialysis and 8% transitioned to home-hemodialysis. Conclusions. Our findings suggest measures to ensure proper catheter placement and limiting infectious complications should be primary areas of focus in order to promote technique retention. Lastly, more focused education about home-hemodialysis as an option may allow those on PD who are beginning to demonstrate signs of technique failure to stay on home therapy.

Neighborhood socioeconomic status, race, and mortality in young adult dialysis patients

Young blacks receiving dialysis have an increased risk of death compared with whites in the United States. Factors influencing this disparity among the young adult dialysis population have not been well explored. Our study examined the relation of neighborhood socioeconomic status (SES) and racial differences in mortality in United States young adults receiving dialysis. We merged US Renal Data System patient-level data from 11,027 black and white patients ages 18-30 years old initiating dialysis between 2006 and 2009 with US Census data to obtain neighborhood poverty information for each patient. We defined low SES neighborhoods as those neighborhoods in U.S. Census zip codes with ≥20% of residents living below the federal poverty level and quantified race differences in mortality risk by level of neighborhood SES. Among patients residing in low SES neighborhoods, blacks had greater mortality than whites after adjusting for baseline demographics, clinical characteristics, rurality, and access to care factors. This difference in mortality between blacks and whites was significantly attenuated in higher SES neighborhoods. In the United States, survival between young adult blacks and whites receiving dialysis differs by neighborhood SES. Additional studies are needed to identify modifiable factors contributing to the greater mortality among young adult black dialysis patients residing in low SES neighborhoods.

Characterization of the BRAZPD II cohort and description of trends in peritoneal dialysis outcome across time periods

Observational studies from different regions of the world provide valuable information in patient selection, clinical practice, and their relationship to patient and technique outcome. The present study is the first large cohort providing patient characteristics, clinical practice, patterns and their relationship to outcomes in Latin America. The objective of the present study was to characterize the cohort and to describe the main determinants of patient and technique survival, including trends over time of peritoneal dialysis (PD) initiation and treatment. This was a nationwide cohort study in which all incident adult patients on PD from 122 centers were studied. Patient demographics, socioeconomic and laboratory values were followed from December 2004 to January 2011 and, for comparison purposes, divided into 3 groups according to the year of starting PD: 2005/06, 2007/08 and 2009/10. Patient survival and technique failure (TF) were analyzed using the competing risk model of Fine and Gray. All patients active at the end of follow-up were treated as censored. In contrast, all patients who dropped the study for any reason different from the primary event of interest were treated as competing risk. Significance was set to a p level of 0.05. A total of 9,905 patients comprised the adult database, 7,007 were incident and 5,707 remained at least 90 days in PD. The main cause of dropout was death (54%) and of TF was peritonitis (63%). Technique survival at 1, 2, 3, 4, and 5 years was 91%, 84%, 77%, 68%, and 58%, respectively. There was no change in TF during the study period but 3 independent risk factors were identified: lower center experience, lower age, and automated PD (APD) as initial therapy. Cardiovascular disease (36%) was the main cause of death and the overall patient survival was 85%, 74%, 64%, 54%, and 48% at 1, 2, 3, 4, and 5 years, respectively. Patient survival improved along all study periods: compared to 2005/2006, patients starting at 2007/2008 had a relative risk reduction (SHR) of 0.83 (95% confidence interval [CI] 0.72 - 0.95); and starting in 2009/2010 of 0.69 (95% CI 0.57 - 0.83). The independent risk factors for mortality were diabetes, age > 65 years, previous hemodialysis, starting PD modality, white race, low body mass index (BMI), low educational level, center experience, length of pre-dialysis care, and the year of starting PD. We observed an improvement in patient survival along the years. This finding was sustained even after correction for several confounders and using a competing risk approach. On the other hand, no changes in technique survival were found.

Association of ethnicity and survival in peritoneal dialysis: a cohort study of incident patients in Brazil

BACKGROUND

There are no available epidemiologic studies about the impact of ethnicity on outcomes of patients treated with peritoneal dialysis (PD) in South America. This study aims to assess the effect of ethnicity on the mortality of incident PD patients in Brazil.

STUDY DESIGN

Prospective observational cohort study of incident patients treated with PD.

SETTINGS & PARTICIPANTS

Patients 18 years or older who started PD therapy between December 2004 and October 2007 in 114 Brazilian dialysis centers.

PREDICTORS

Self-reported ethnicity defined by the Brazilian Institute of Geography and Statistics as black and brown versus white patients and baseline demographic, socioeconomic, clinical, and laboratory data were collected at baseline.

OUTCOME

Mortality, using cumulative mortality curves in which kidney transplantation and transfer to hemodialysis therapy were treated as competing end points. Multivariate Cox proportional hazards analysis was used to adjust for gradually more potential explanatory variables, censored for kidney transplantation and transfer to hemodialysis therapy. Analyses were performed for all patients, as well as stratified for elderly (aged ≥65 years) and nonelderly patients.

RESULTS

1,370 patients were white, 516 were brown, and 273 were black. The competing-risk model showed higher mortality in white patients compared with black and brown patients. With white patients as the reference, Cox proportional hazards analysis showed a crude HR for mortality of 0.77 (95% CI, 0.56-1.05) for black and 0.74 (95% CI, 0.59-0.94) for brown patients. After adjusting for potential explanatory factors, HRs were 0.67 (95% CI, 0.48-0.95) and 0.77 (95% CI, 0.43-1.01), respectively. The same results were observed in elderly and nonelderly patients.

LIMITATIONS

Ethnicity was self-determined and some misclassification might have occurred.

CONCLUSIONS

Black and brown Brazilian incident PD patients have a lower mortality risk compared with white patients.

Determinants of peritoneal dialysis technique failure in incident US patients

OBJECTIVES

Switching from peritoneal dialysis (PD) to hemodialysis (HD) is undesirable, because of complications from temporary vascular access, disruption of daily routine, and higher costs. Little is known about the role that social factors play in technique failure.

DESIGN, SETTING, PARTICIPANTS, MEASUREMENTS

We followed for 3 years a nationally representative cohort of US patients who initiated PD in 1996 - 1997. Technique failure was defined as any switch from PD to HD for 30 days or more. We used Cox regression to examine associations between technique failure and demographic, medical, social, and pre-dialysis factors. We estimated hazard ratios (HRs) with 95% confidence intervals (CIs).

RESULTS

We identified an inception cohort of 1587 patients undergoing PD. In multivariate analysis, female sex (HR: 0.78; 95% CI: 0.64 to 0.95) was associated with lower rates of technique failure, and black race [compared with white race (HR: 1.48; 95% CI: 1.20 to 1.82)] and receiving Medicaid (HR: 1.48; 95% CI: 1.17 to 1.86) were associated with higher rates. Compared with patients who worked full-time, those who were retired (HR: 1.49; 95% CI: 1.07 to 2.08) or disabled (HR: 1.38; 95% CI: 1.01 to 1.88) had higher rates of failure. Patients with a systolic blood pressure of 140 - 160 mmHg had a higher rate of failure than did those with a pressure of 120 - 140 mmHg (HR: 1.24; 95% CI: 1.00 to 1.52). Earlier referral to a nephrologist (>3 months before dialysis initiation) and the primary decision-maker for the dialysis modality (physician vs patient vs shared) were not associated with technique failure.

CONCLUSIONS

This study confirms that several socio-demographic factors are associated with technique failure, emphasizing the potential importance of social and financial support in maintaining PD.

The effect of low glucose degradation product, neutral pH versus standard peritoneal dialysis solutions on peritoneal membrane function: the balANZ trial

Background

The balANZ trial recently reported that neutral pH, low glucose degradation product (biocompatible) peritoneal dialysis (PD) solutions significantly delayed anuria and reduced peritonitis rates compared with conventional solutions. This article reports a secondary outcome analysis of the balANZ trial with respect to peritoneal membrane function.

Methods

Adult, incident PD patients with residual renal function were randomized to receive either biocompatible or conventional (control) PD solutions for 2 years. Peritoneal equilibration tests were performed at 1, 6, 12, 18 and 24 months. Peritoneal small solute clearances and ultra-filtration (UF) were measured at 3, 6, 9, 12, 18 and 24 months.

Results

Of the 185 patients recruited into the trial, 85 patients in the Balance group and 82 patients in the control group had peritoneal membrane function evaluated. Mean 4-h dialysate:plasma creatinine ratios (D:P Cr 4h) at 1 month were significantly higher in the Balance group compared with controls (0.67 ± 0.10 versus 0.62 ± 0.10, P = 0.002). Over the 2-year study period, mean D:P Cr 4 h measurements remained stable in the Balance group but increased significantly in controls [difference −0.004 per month, 95% confidence interval (95% CI) −0.005 to −0.002, P < 0.001]. Similar results were obtained for dialysate glucose ratios (D/D0 glucose). Peritoneal UF was significantly lower in the Balance group than in controls at 3 and 6 months. Over the 2-year study period, peritoneal UF increased significantly in the Balance group but remained stable in controls (difference 24 mL/day/month, 95% CI 9–39, P = 0.002). No differences in peritoneal small solute clearances, prescribed dialysate fill volumes or peritoneal glucose exposure were observed between the two groups.

Conclusions

Biocompatible and conventional PD solutions exert differential effects on peritoneal small solute transport rate and UF over time. Adequately powered trials assessing the impact of these differential membrane effects on PD technique and patient survival rates are warranted.

Donor race and outcomes in kidney transplant recipients

BACKGROUND

African Americans are at greater risk to reach end-stage renal disease and this risk may carry over in a kidney transplant recipient after kidney transplantation.

METHODS

Linking the five-yr patient data of a large dialysis organization to the Scientific Registry of Transplant Recipients, we identified 13 692 hemodialysis patients who underwent first kidney transplantation. Mortality or graft failure and delayed graft function risks were estimated by Cox's regression (hazard ratio [HR] and 95% confidence interval) and logistic regression, respectively.

RESULTS

Patients were 48 ± 14 yr old and included 39% women and 26% patients with diabetes. After adjusting for several relevant clinical and transplant-related variables, African American donor race was associated with higher all-cause mortality, with HR of 1.39 (1.09-1.78) for all-cause mortality, 1.80 (1.17-2.76) for cardiovascular mortality, 1.30 (1.03-1.64) for death-censored graft loss and 1.31 (1.10-1.57) for combined outcome over the six-yr observation period. In the non-African American recipient subcohort, but not in the African American recipient subcohort, African American donor race was associated with higher risk of death-censored graft loss (2.24 [1.44-3.49]) in our fully adjusted model.

CONCLUSIONS

African American donor race was associated with increased all-cause and cardiovascular mortality and graft loss.

Dialysis type may predict carotid intima media thickness and plaque presence in end-stage renal disease patients

INTRODUCTION

Carotid intima media thickness (CIMT) and carotid plaques (CP) were shown to be independent predictors of mortality in end-stage renal disease (ESRD) patients. In this study, the authors aimed to compare the two dialysis modalities for CIMT and CP presence (CPP).

METHODS

ESRD patients who had been on the same renal replacement therapy for at least 24 months were selected. CIMT, CPP, known risk factors, and laboratory parameters for atherosclerosis were determined for each patient.

RESULTS

A total of 77 hemodialysis (HD) patients (68% male, 47.6±17.0 years), 61 continuous ambulatory peritoneal dialysis (CAPD) patients (51% male, 45.3±13.9 years), and 36 age- and sex-matched controls (61% male, 43.3±10.6 years) were included. The mean CIMT (m-CIMT) were 0.99±0.24, 0.86±0.22, and 0.60±0.13 mm in the HD, CAPD, and control groups, respectively (HD vs. CAPD, P=0.001; HD vs. control, P<0.001; and CAPD vs. control, P<0.001). The CPP occurred more frequently in the HD group compared to the CAPD group (64% vs. 39%, respectively, P=0.004). The backward linear and logistic regression analysis of potential confounders revealed that both m-CIMT and CPP was independently associated with dialysis type (beta=0.249, P=0.008; and odds ratio [OR]=4.11, 95% CI, 1.72 to 6.73, P=0.015, respectively).

CONCLUSION

The authors have shown that dialysis type may be an independent predictor of m-CIMT and CPP in long-term ESRD patients.

The role of psychosocial factors in ethnic differences in survival on dialysis in the Netherlands

INTRODUCTION

Ethnic minority patients on dialysis are reported to have better survival rates relative to Caucasians. The reasons for this finding are not fully understood and European studies are scarce. This study examined whether ethnic differences in survival could be explained by patient characteristics, including psychosocial factors.

METHODS

We analysed data of the Netherlands Cooperative Study on the Adequacy of Dialysis study, an observational prospective cohort study of patients who started dialysis between 1997 and 2007 in the Netherlands. Ethnicity was classified as Caucasian, Black or Asian, assessed by local nurses. Data collected at the start of dialysis treatment included demographic, clinical and psychosocial characteristics. Psychosocial characteristics included data on health-related quality of life (HRQoL), mental health status and general health perception. Cox proportional hazards analysis was used to explore ethnic survival differences.

RESULTS

One thousand seven hundred and ninety-one patients were Caucasian, 45 Black and 108 Asian. The ethnic groups differed significantly in age, residual glomerular filtration rate, diabetes mellitus, erythropoietin use, plasma calcium, parathormone and creatinine, marital status and general health perception. No ethnic differences were found in HRQoL and mental health status. Crude hazard ratios (HRs) for mortality for Caucasians compared to Blacks and Asians were 3.1 [95% confidence interval (CI) 1.6-5.9] and 1.1 (95% CI 0.9-1.5), respectively. After adjustment for a range of potential explanatory variables, including psychosocial factors, the HRs were 2.5 (95% CI 1.2-4.9) compared with Blacks and 1.2 (95% CI 0.9-1.6) compared with Asians.

CONCLUSIONS

Although patient numbers were rather small, this study demonstrates, with 95% confidence, better survival for Black compared to Caucasian dialysis patients and equal survival for Asian compared to Caucasian dialysis patients in the Netherlands. This could not be explained by patient characteristics, including psychosocial factors.

Racial and ethnic differences in the association of body mass index and survival in maintenance hemodialysis patients

BACKGROUND

In maintenance hemodialysis (HD) patients, overweight and obesity are associated with survival advantages. Given the greater survival of maintenance HD patients who are minorities, we hypothesized that increased body mass index (BMI) is associated more strongly with lower mortality in blacks and Hispanics relative to non-Hispanic whites.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

We examined a 6-year (2001-2007) cohort of 109,605 maintenance HD patients including 39,090 blacks, 17,417 Hispanics, and 53,098 non-Hispanic white maintenance HD outpatients from DaVita dialysis clinics. Cox proportional hazards models examined the association between BMI and survival.

PREDICTORS

Race and BMI.

OUTCOMES

All-cause mortality.

RESULTS

Patients had a mean age of 62 ± 15 (standard deviation) years and included 45% women and 45% patients with diabetes. Across 10 a priori-selected BMI categories (<18-≥40 kg/m(2)), higher BMI was associated with greater survival in all 3 racial/ethnic groups. However, Hispanic and black patients experienced higher survival gains compared with non-Hispanic whites across higher BMI categories. Hispanics and blacks in the ≥40-kg/m(2) category had the largest adjusted decrease in death HR with increasing BMI (0.57 [95% CI, 0.49-0.68] and 0.63 [95% CI, 0.58-0.70], respectively) compared with non-Hispanic whites in the 23- to 25-kg/m(2) group (reference category). In linear models, although the inverse BMI-mortality association was observed for all subgroups, overall black maintenance HD patients showed the largest consistent decrease in death HR with increasing BMI.

LIMITATIONS

Race and ethnicity categories were based on self-identified data.

CONCLUSIONS

Whereas the survival advantage of high BMI is consistent across all racial/ethnic groups, black maintenance HD patients had the strongest and most consistent association of higher BMI with improved survival.

Association of race and age with survival among patients undergoing dialysis

CONTEXT

Many studies have reported that black individuals undergoing dialysis survive longer than those who are white. This observation is paradoxical given racial disparities in access to and quality of care, and is inconsistent with observed lower survival among black patients with chronic kidney disease. We hypothesized that age and the competing risk of transplantation modify survival differences by race.

OBJECTIVE

To estimate death among dialysis patients by race, accounting for age as an effect modifier and kidney transplantation as a competing risk.

DESIGN, SETTING, AND PARTICIPANTS

An observational cohort study of 1,330,007 incident end-stage renal disease patients as captured in the United States Renal Data System between January 1, 1995, and September 28, 2009 (median potential follow-up time, 6.7 years; range, 1 day-14.8 years). Multivariate age-stratified Cox proportional hazards and competing risk models were constructed to examine death in patients who receive dialysis.

MAIN OUTCOME MEASURES

Death in black vs white patients who receive dialysis.

RESULTS

Similar to previous studies, black patients undergoing dialysis had a lower death rate compared with white patients (232,361 deaths [57.1% mortality] vs 585,792 deaths [63.5% mortality], respectively; adjusted hazard ratio [aHR], 0.84; 95% confidence interval [CI], 0.83-0.84; P <.001). However, when stratifying by age and treating kidney transplantation as a competing risk, black patients had significantly higher mortality than their white counterparts at ages 18 to 30 years (27.6% mortality vs 14.2%; aHR, 1.93; 95% CI, 1.84-2.03), 31 to 40 years (37.4% mortality vs 26.8%; aHR, 1.46; 95% CI, 1.41-1.50), and 41 to 50 years (44.8% mortality vs 38.0%; aHR, 1.12; 95% CI, 1.10-1.14; P <.001 for interaction terms between race and each aforementioned age category), as opposed to patients aged 51 to 60 years (51.5% vs 50.9%; aHR, 0.93; 95% CI, 0.92-0.94), 61 to 70 years (64.9% vs 67.2%; aHR, 0.87; 95% CI, 0.86-0.88), 71 to 80 years (76.1% vs 79.7%; aHR, 0.85; 95% CI, 0.84-0.86), and older than 80 years (82.4% vs 83.6%; aHR, 0.87; 95% CI, 0.85-0.88).

CONCLUSIONS

Overall, among dialysis patients in the United States, there was a lower risk of death for black patients compared with their white counterparts. However, the commonly cited survival advantage for black dialysis patients applies only to older adults, and those younger than 50 years have a higher risk of death.

Rationale and design of the balANZ trial: a randomised controlled trial of low GDP, neutral pH versus standard peritoneal dialysis solution for the preservation of residual renal function

Background

The main hypothesis of this study is that neutral pH, low glucose degradation product (GDP) peritoneal dialysis (PD) fluid better preserves residual renal function in PD patients over time compared with conventional dialysate.

Methods/Design

Inclusion criteria are adult PD patients (CAPD or APD) aged 18-81 years whose first dialysis was within 90 days prior to or following enrolment and who have a residual GFR ≥ 5 ml/min/1.73 m², a urine output ≥ 400 ml/day and an ability to understand the nature and requirements of this trial. Pregnant or lactating patients or individuals with an active infection at the time of enrolment, a contra-indication to PD or participation in any other clinical trial where an intervention is designed to moderate rate of change of residual renal function are excluded. Patients will be randomized 1:1 to receive either neutral pH, low GDP dialysis solution (Balance^®) or conventional dialysis solution (Stay.safe^®) for a period of 2 years. During this 2 year study period, urinary urea and clearance measurements will be performed at 0, 3, 6, 9, 12, 18 and 24 months. The primary outcome measure will be the slope of residual renal function decline, adjusted for centre and presence of diabetic nephropathy. Secondary outcome measures will include time from initiation of peritoneal dialysis to anuria, peritoneal small solute clearance, peritoneal transport status, peritoneal ultrafiltration, technique survival, patient survival, peritonitis rates and adverse events. A total of 185 patients has been recruited into the trial.

Discussion

This investigator-initiated study has been designed to provide evidence to help nephrologists determine the optimal dialysis solution for preserving residual renal function in PD patients.

Trial Registration

Australian New Zealand Clinical Trials Registry Number: ACTRN12606000044527

Geographic and temporal trends in peritoneal dialysis services in the United States between 1995 and 2003

BACKGROUND

Peritoneal dialysis (PD) is the preferred dialysis modality for many patients with end-stage renal disease (ESRD) in the United States. However, in sharp contrast to the high rates of PD use in other industrialized countries, PD use in the United States is low and decreasing. PD availability is a necessary condition for PD use; however, little is known about the availability and geographic distribution of PD services. This study describes trends in the regional supply of PD services in dialysis facilities between 1995 and 2003.

STUDY DESIGN

Longitudinal cohort study.

SETTING & PARTICIPANTS

Nonfederal outpatient dialysis facilities treating patients with ESRD in the United States using data from the US Renal Data System.

PREDICTORS

Annual ESRD patient and dialysis facility composition in hospital referral regions.

OUTCOME

Annual proportion of dialysis facilities offering PD treatment services in hospital referral regions.

RESULTS

The average proportion of facilities offering PD services in hospital referral regions was 56% in 1996, which decreased to 47% in 2003. There was geographic variation in PD services, with greater PD availability in metropolitan cities (compared with rural regions) and the Northeast (relative to the South and Midwest). Variation in PD availability was not explained by disease trends or patient characteristics believed to be important for PD use. An increasing regional presence of chain-affiliated facilities was associated with less PD supply.

LIMITATIONS

Accuracy of patient registry data, inability to account for consolidation of PD services among chain providers, sensitivity of results to definition of regional markets.

CONCLUSIONS

The small and decreasing availability of PD therapy seems counterintuitive given its demonstrated appeal to patients and payers. Further research is needed to investigate dialysis facilities' role in the underuse of a potentially useful therapy.

Technique Failure and Center Size in a Large Cohort of Peritoneal Dialysis Patients in a Defined Geographic Area

Background

Hemodialysis (HD) and peritoneal dialysis (PD) are both viable options for renal replacement therapy. Technique failure has been shown to be a major problem in PD therapy.

Objective

To examine the relationship between center size and PD technique failure.

Setting

ESRD Network #1 (NW1).

Design

Retrospective review of NW1 database.

Patients and Methods

5003 incident PD patients between 2001 and 2005 in 105 PD units were included. Patients were grouped into 2 based on center size: group A, patients in units with ≤25 patients, and group B, patients in units with >25 patients. Outcome measures were analyzed for the first and second years of PD therapy. Patients were censored at transplantation, transfer to HD, or death.

Outcome Measures

Technique failure and mortality reported as death in Standard Information Management Systems (SIMS) database (NW1 data system).

Results

Technique failure rates were significantly higher in group A for year 1 (odds ratio: 1.36, p = 0.005) and for year 2 (odds ratio: 1.35, p = 0.03). Mortality rates were not statistically different between the 2 groups.

Conclusion

Technique failure was higher in units with ≤25 patients than in units with >25 patients. There was no difference in mortality between the 2 groups. The majority of patients in NW1 receive care in small units.

American Society of Diagnostic and Interventional Nephrology Section Editor: Stephen Ash: Does Catheter Insertion by Nephrologists Improve Peritoneal Dialysis Utilization? A Multicenter Analysis

In contrast to hemodialysis (HD), peritoneal dialysis (PD) remains an underutilized form of renal replacement therapy in the United States. Although a variety of factors have been deemed responsible, timely insertion of a PD catheter may also be a contributory factor. We conducted a multicenter analysis to examine whether the establishment of a program for PD catheter insertion by nephrologists has a positive impact on the growth in the number of patients using PD. Data for catheter insertion performed by nephrologists were collected from three centers. Any change in the prevalent PD population at each respective center was compared to the number of PD patients during the period having the traditional surgical approach. Nephrologists at the three centers used the peritoneoscopic technique and performed catheter insertion under local anesthesia. In center 1, the PD population remained stable at between 38 and 45 patients (approximately 16% of the total end-stage renal disease [ESRD] population) from 1993 to 2001. Nephrologists initiated a program for PD catheter insertion in 2001. The number of PD patients has increased to 101 (32% of the ESRD population). In center 2, the PD population remained stable at between 70 and 78 patients (approximately 17%) between 1988 and 1990. Catheter insertion by interventional nephrologists began in 1991. The number of PD patients has increased to 125 (22%). In center 3, the PD population remained at 20-30 patients (approximately 18%) between 1988 and 1991. Catheter placement by nephrologists was initiated in 1991. The number of PD patients increased to 97 (27%). Catheter insertion by interventional nephrologists was suspended in 2001. The number of PD patients has gradually declined to 25 (6%). This study suggests that catheter insertion by the nephrologist can have a positive impact on the utilization of PD.

Does peritoneal dialysis catheter insertion by interventional nephrologists enhance peritoneal dialysis penetration?

Traditionally peritoneal dialysis (PD) catheter was implanted by surgeons using mini-laparotomy or open technique in Malaysia. We introduced peritoneoscopic Tenckhoff catheter insertion technique since the beginning of our PD program. Data were collected from the start of our PD program in February 2006 until April 2008. All Tenckhoff catheters were inserted by nephrologists using the peritoneoscope technique. We also compare the penetration rate of PD versus hemodialysis (HD) in our center, as well as comparing to national PD penetration rate. There were 83 patients who underwent 91 peritoneoscope Tenckhoff catheter insertion procedures from March 2006 until April 2008. The patients were mostly female (66%) with the mean age of 51.99 +/- 1.78 years and the majority (67%) of them were diabetics. All together there were 749.7 patient-months at risk and the overall peritonitis rate was 1 in 93.7 patient-months. The 1-year catheter survival was 86.5%. Primary catheter failure (defined as failure of the catheter within 1 month of insertion) occurred in 16 procedures (17.6%). The main cause of catheter malfunction was catheter tip migration and omentum wrap. The penetration ratio of PD when compared with HD in our center is 44.8%, which is about 4.5 times the national average. With our integrated care approach where nephrologist was heavily involved from the outset of renal replacement therapy discussion, PD access implantation to the assistance of spoke person to whom new patient can identify with, we were able to achieve PD penetration rate which far exceeds that of the national average.

Higher serum creatinine concentrations in black patients with chronic kidney disease: beyond nutritional status and body composition

BACKGROUND AND OBJECTIVES

Serum creatinine concentrations tend to be higher in black than white individuals and people of other races or ethnicities. These differences have been assumed to be largely related to race-related differences in body composition, especially muscle mass.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In a diverse population of hemodialysis patients, we compared mean serum creatinine concentrations in black versus nonblack patients, adjusting for case mix (age, gender, diabetes, and dialysis vintage), body size (height, weight), laboratory parameters of nutritional status (albumin, predialysis blood urea nitrogen, transferrin, phosphorus, glucose), dialysis dosage (urea reduction ratio), and parameters of bioelectrical impedance (resistance and reactance), proxies for body composition.

RESULTS

Adjusted mean serum creatinine concentrations were significantly higher in black versus nonblack patients (11.7 versus 10.0 mg/dl; P < 0.0001). Black patients were roughly four-fold more likely to have a serum creatinine concentration >10 mg/dl and six-fold more likely to have a serum creatinine concentration >15 mg/dl. Higher serum creatinine concentrations were associated with a lower relative risk for death (0.93; 95% confidence interval 0.88 to 0.98 per mg/dl); the association was slightly more pronounced among nonblack patients.

CONCLUSIONS

Serum creatinine concentrations are significantly higher in black compared with nonblack hemodialysis patients; these differences are not readily explained by differences in nutritional status or body composition.

Increased survival of immigrant compared to native dialysis patients in an urban setting in the Netherlands

BACKGROUND

Data from the United States and Canada suggest that survival rates of Caucasian dialysis patients are lower compared to those of black patients and patients from Asian regions. Information regarding the survival rate of immigrant dialysis patients in Europe is scarce.

METHODS

We retrospectively analysed incident haemodialysis (HD) and peritoneal dialysis (PD) patients who entered an Amsterdam renal service between January 1996 and December 2005. To explore the origin of differences in survival between natives and immigrants, we ran a series of Cox models with adjustment for demographic, clinical and laboratory variables at baseline and initial adequacy variables.

RESULTS

Of 303 incident dialysis patients, 58% were natives and 42% were immigrants. Fifty-nine percent of natives and 54% of immigrants had HD as initial treatment modality. At initiation of dialysis, native patients were older and had higher rates of vascular and coronary artery diseases and malignancies and a lower prevalence of hypertension. Glomerulonephritis was more common among immigrants as primary kidney disease. Mean haematocrit and calcium levels for natives were higher compared to immigrants. Cox proportional hazards analysis revealed an increased relative mortality risk (RR) of 2.7 [95% confidence interval (CI) 1.9-3.9] for natives compared to immigrants. Adjustment for age at the start of dialysis attenuated the RR to 1.9 (CI 1.3-2.7). Adjustment for the other variables did not materially influence this RR.

CONCLUSIONS

We demonstrate increased survival for immigrant compared to native dialysis patients in an urban setting in the Netherlands. This survival advantage is only partly explained by younger age of immigrants at the start of dialysis compared to native patients.

Comparison of hemodialysis and peritoneal dialysis survival in The Netherlands

Considerable geographic variation exists in the relative use of hemodialysis (HD) vs peritoneal dialysis (PD). Studies comparing survival between these modalities have yielded conflicting results. Our aim was to compare the survival of Dutch HD and PD patients. We developed Cox regression models using 16 643 patients from the Dutch End-Stage Renal Disease Registry (RENINE) adjusting for age, gender, primary renal disease, center of dialysis, year of start of renal replacement therapy, and included several interaction terms. We assumed definite treatment assignment at day 91 and performed an intention-to-treat analysis, censoring for transplantation. To account for time dependency, we stratified the analysis into three time periods, >3-6, >6-15, and >15 months. For the first period, the mortality hazard ratio (HR) of PD compared with HD patients was 0.26 (95% confidence interval (CI) 0.17-0.41) for 40-year-old non-diabetics, which increased with age and presence of diabetes to 0.95 (95% CI 0.64-1.39) for 70-year-old patients with diabetes as primary renal disease. The HRs of the second period were generally higher. After 15 months, the HR was 0.86 (95% CI 0.74-1.00) for 40-year-old non-diabetics and 1.42 (95% CI 1.23-1.65) for 70-year-old patients with diabetes as primary renal disease. We conclude that the survival advantage for Dutch PD compared with HD patients decreases over time, with age and in the presence of diabetes as primary disease.

Association of patient autonomy with increased transplantation and survival among new dialysis patients in the United States

BACKGROUND

It is unclear whether patients with chronic kidney disease who are more autonomous in medical decision making have better outcomes than those who are not. We examined the contribution of patient autonomy to treatment selection (peritoneal dialysis versus hemodialysis) and subsequent association with transplantation and survival.

METHODS

Data were obtained from the Dialysis Morbidity and Mortality Study Wave 2, a national random sample of 4,025 new dialysis patients enrolled during 1996 and 1997 and followed up until October 31, 2001. Responders were asked to quantify their contribution to treatment selection and were grouped based on perceived degree of participation as patient led, team led, or patient and team led. Groups were compared and subsequent outcomes were evaluated by using Cox regression.

RESULTS

Six hundred thirty-six patients (26.3%) reported a patient-led decision, 860 patients (35.6%) reported a team-led decision, and 922 patients (38.1%) reported a patient-and-team-led decision in treatment assignment. Unadjusted death rates were significantly lower (127 versus 159 versus 207 deaths/1,000 patient-years at risk; P < 0.0001), and transplantation rates were significantly higher (103 versus 88 versus 41 transplantations/1,000 patient-years at risk; P < 0.0001) for patients reporting the greatest contribution to modality selection. With adjustment for case mix, mortality risks were lowest (relative risk [RR], 0.84; 95% confidence interval [CI], 0.71 to 0.99) and transplantation rates were highest (RR, 1.44; 95% CI, 1.07 to 1.93) for the patient-led group.

CONCLUSION

Although the contribution of patient selection factors cannot be completely ignored, this analysis supports an association of patient autonomy with transplantation and survival. Greater efforts to empower patients with chronic kidney disease during the period before end-stage renal disease may improve clinical outcomes.

Impact of initial dialysis modality and modality switches on Medicare expenditures of end-stage renal disease patients

BACKGROUND

The number of end-stage renal disease (ESRD) enrollees and Medicare expenditures have increased dramatically. Pathways and associated Medicare expenditures in ESRD treatment need to be examined to potentially improve the efficiency of care.

METHODS

This study examines the impact of initial dialysis modality choice and subsequent modality switches on Medicare expenditure in a 3-year period. The Dialysis Morbidity and Mortality Study Wave 2 data by the United States Renal Data System (USRDS) is used along with the USRDS Core CD and USRDS claims data.

RESULTS

A total of 3423 incident dialysis patients (approximately equal number of peritoneal dialysis and hemodialysis) were included in the analysis. Unadjusted average annual Medicare expenditure (in 2004 dollars) for peritoneal dialysis as first modality was 53,277 dollars(95% CI 50,626 dollars-55,927 dollars), and 72,189 dollars (95% CI 67,513 dollars-76,865 dollars) for hemodialysis. Compared to "hemodialysis, no switch" subgroup, "peritoneal dialysis, no switch" had a significantly lower annual expenditure (44,111 dollars vs. 72,185 dollars) (P < 0.001). "Peritoneal dialysis, with at least one switch" and "hemodialysis, with at least one switch" had a lower or similar annual expenditure of 66,639 dollars and 72,335 dollars, respectively. After adjusting for patient characteristics, annual Medicare expenditure was still significantly lower for patients with peritoneal dialysis as the initial modality (56,807 dollars vs. 68,253 dollars) (P < 0.001). Similarly, compared to "hemdialysis, no switch" subgroup, "peritoneal dialysis, no switch" and "peritoneal dialysis, with at least one switch" had a significantly lower total expenditure. Further analysis showed that time-to-first switch also independently impacted total expenditure.

CONCLUSION

Initial modality choice (peritoneal dialysis or hemodialysis) and subsequent modality switches had significant implications for Medicare expenditure on ESRD treatments.

Peritoneal dialysis access-related procedures by nephrologists

Traditionally the placement of a peritoneal dialysis (PD) catheter in a patient with end-stage renal disease (ESRD) has been accomplished by a surgeon and using general anesthesia. This approach often introduces delays in starting PD, incurs additional costs in utilizing an operating room as well as anesthesia services, and introduces the mortality risk associated with general anesthesia. Recent data have emphasized that interventional nephrologists can safely and successfully perform PD access procedures. In this context, operating room facilities and staff and anesthesia services are not required and catheter insertion can be performed in a procedure room using local anesthesia, thereby reducing costs and completely bypassing the mortality risk associated with general anesthesia. When performed by a nephrologist, the catheter insertion can be accomplished swiftly and dialysis therapy initiated in a timely manner. Once begun, the success of PD hinges on reliable and long-term access to the peritoneal cavity. Prospective randomized and nonrandomized studies have shown that PD catheters peritoneoscopically placed by nephrologists have fewer complications (infection, exit site leak) and longer catheter survival rates than those inserted surgically. Although PD offers a variety of advantages, it remains an underutilized form of renal replacement therapy. To counteract PD underutilization, at least two separate centers have demonstrated a positive impact on the growth of the PD population when catheter insertion is performed by nephrologists. This article presents PD access-related procedures currently performed by interventional nephrologists. Furthermore, some of the complicating issues (bowel perforation, catheter migration, prior abdominal surgery) related to PD catheter insertion and management are also discussed.

Impact of dialysis modality on survival of new ESRD patients with congestive heart failure in the United States

BACKGROUND

It is hypothesized, but not proven, that peritoneal dialysis might be the optimal treatment for end-stage renal disease (ESRD) patients with established congestive heart failure (CHF) through better volume regulation compared with hemodialysis.

METHODS

National incidence data on 107,922 new ESRD patients from the Center for Medicare and Medicaid Services (CMS) Medical Evidence Form were used to test the hypothesis that peritoneal dialysis was superior to hemodialysis in prolonging survival of patients with CHF. Nonproportional Cox regression models evaluated the relative hazard of death for patients with and without CHF by dialysis modality using primarily the intent-to-treat but also the as-treated approach. Diabetics and nondiabetics were analyzed separately.

RESULTS

The overall prevalence of CHF was 33% at ESRD initiation. There were 27,149 deaths (25.2%), 5423 transplants (5%), and 3753 (3.5%) patients lost to follow-up over 2 years. Adjusted mortality risks were significantly higher for patients with CHF treated with peritoneal dialysis than hemodialysis [diabetics, relative risk (RR) = 1.30, 95% confidence interval (CI) 1.20 to 1.41; nondiabetics, RR = 1.24, 95% CI 1.14 to 1.35]. Among patients without CHF, adjusted mortality risk were higher only for diabetic patients treated with peritoneal dialysis compared with hemodialysis (RR = 1.11, 95% CI 1.02 to 1.21) while nondiabetics had similar survival on peritoneal dialysis or hemodialysis (RR = 0.97, 95% CI 0.91 to 1.04).

CONCLUSION

New ESRD patients with a clinical history of CHF experienced poorer survival when treated with peritoneal dialysis compared with hemodialysis. These data suggest that peritoneal dialysis may not be the optimal choice for new ESRD patients with CHF perhaps through impaired volume regulation and worsening cardiomyopathy.

Peritoneal dialysis underutilization: the impact of an interventional nephrology peritoneal dialysis access program

Peritoneal dialysis (PD) is an underutilized form of renal replacement therapy. Recent data have emphasized that only 12% of end-stage renal disease (ESRD) patients are initiated on this form of therapy in the United States. Patients requiring PD have most often been referred to general surgeons for catheter placement. This has incurred additional delays in starting treatment and loss of decision-making control by the referring nephrologist. To address this issue, we developed and incorporated our own PD access placement program into the preexisting chronic kidney disease (CKD) education program. To date, 46 patients have undergone 71 procedures. These included 51 (72%) PD catheter insertions, 14 (20%) removals, and 6 (8%) repositioning procedures for poor drainage. PD catheter insertion was performed peritoneoscopically under local anesthesia and a Fogarty catheter was used to reposition a migrated catheter. All of the procedures were performed by nephrologists in a dedicated interventional nephrology (IN) laboratory. All six repositioning procedures failed to restore optimal drainage. Five of these patients had the catheter removed and a new catheter placed during the same procedure. Of these five patients, one had recurrence of poor drainage and opted for hemodialysis (HD). The sixth patient declined reinsertion and chose HD. Of the remaining seven removal procedures, three were due to fungal peritonitis, one due to bowel perforation, one due to severe depression, one due to transplant, and one catheter was removed at the request of the primary physician in a terminally ill patient. Eight of the 51 catheter insertions were during the initial admission of a catastrophic dialysis start. Two of these patients started acute PD and avoided catheter placement for HD. Thirty-seven of 46 patients have a functional PD catheter with a follow-up of 8.6 +/- 0.8 (mean +/- SE) months. During an 18-month period our PD population has increased from 43 to 80 patients. We conclude that a dedicated PD access placement program coupled with a CKD education program can have a dramatic impact on patient choice and PD growth.

Hypoalbuminemia in acute illness: is there a rationale for intervention? A meta-analysis of cohort studies and controlled trials

OBJECTIVE

To determine whether hypoalbuminemia is an independent risk factor for poor outcome in the acutely ill, and to assess the potential of exogenous albumin administration for improving outcomes in hypoalbuminemic patients.

SUMMARY BACKGROUND DATA

Hypoalbuminemia is associated with poor outcomes in acutely ill patients, but whether this association is causal has remained unclear. Trials investigating albumin therapy to correct hypoalbuminemia have proven inconclusive.

METHODS

A meta-analysis was conducted of 90 cohort studies with 291,433 total patients evaluating hypoalbuminemia as an outcome predictor by multivariate analysis and, separately, of nine prospective controlled trials with 535 total patients on correcting hypoalbuminemia.

RESULTS

Hypoalbuminemia was a potent, dose-dependent independent predictor of poor outcome. Each 10-g/L decline in serum albumin concentration significantly raised the odds of mortality by 137%, morbidity by 89%, prolonged intensive care unit and hospital stay respectively by 28% and 71%, and increased resource utilization by 66%. The association between hypoalbuminemia and poor outcome appeared to be independent of both nutritional status and inflammation. Analysis of dose-dependency in controlled trials of albumin therapy suggested that complication rates may be reduced when the serum albumin level attained during albumin administration exceeds 30 g/L.

CONCLUSIONS

Hypoalbuminemia is strongly associated with poor clinical outcomes. Further well-designed trials are needed to characterize the effects of albumin therapy in hypoalbuminemic patients. In the interim, there is no compelling basis to withhold albumin therapy if it is judged clinically appropriate.

Mortality differences by dialysis modality among incident ESRD patients with and without coronary artery disease

It is unclear whether peritoneal dialysis (PD) compared with hemodialysis (HD) confers a survival advantage in end-stage renal disease (ESRD) patients with coronary artery disease (CAD). This hypothesis was tested in a national cohort of 107,922 patients starting dialysis therapy between May 1, 1995, and July 31, 1997. Data on patient characteristics were obtained from the Center for Medicare and Medicaid Services Medical Evidence Form (CMS) and linked to mortality data from the United States Renal Data System (USRDS). Patients were classified on the basis of CAD presence and followed until death or the end of 2 yr. Nonproportional Cox regression models estimated the relative risk (RR) of death for patients with and without CAD by dialysis modality using primarily the intent-to-treat but also the as-treated approach. Diabetic patients (DM) and nondiabetic patients (non-DM) were analyzed separately. Among DM, patients with CAD treated with PD had a 23% higher RR (95% CI, 1.12 to 1.34) compared with similar HD patients, whereas patients without CAD receiving PD had a 17% higher RR (CI, 1.08 to 1.26) compared with HD. Among non-DM, patients with CAD treated with PD had a 20% higher RR (CI. 1.10 to 1.32) compared with HD patients, whereas patients without CAD had similar survival on PD or HD (RR = 0.99; CI, 0.93 to 1.05). The mortality risk for new ESRD patients with CAD differed by treatment modality. In both DM and non-DM, patients with CAD treated with PD had significantly poorer survival compared with HD. Whether differences in solute clearance and/or cardiac risk profiles between PD and HD may explain these findings deserves further investigation.

Comparing mortality of elderly patients on hemodialysis versus peritoneal dialysis: a propensity score approach

The objective of this study was to evaluate differences in mortality over the first year of renal replacement therapy (RRT) between elderly patients starting treatment on hemodialysis (HD) versus peritoneal dialysis (PD). For the period of 1991 to mid-1996, this study defined an inception cohort of all patients aged >65 yr with new-onset chronic RRT who were New Jersey Medicare and/or Medicaid beneficiaries in the year before RRT and who had been diagnosed with renal disease more than 1 yr before RRT. Propensity scores were calculated for first treatment assignment from a large number of baseline covariates. Mortality was then compared among patients initially assigned to HD versus PD using multivariate 90-d interval Cox models controlled for propensity scores and center stratification. Peritoneal dialysis starters had a 16% higher rate of death during the first 90 d of RRT compared with HD patients (hazard ratio [HR], 1.16; 95% confidence interval [CI], 0.96 to 1.42)]. Mortality did not differ between day 91 and 180 (HR, 1.03; 95% CI, 0.71 to 1.51). Thereafter, PD starters again died at a higher rate (HR, 1.45; 95% CI, 1.07 to 1.98). These findings were more pronounced among patients with diabetes. Sensitivity analyses using more stringent criteria to ensure that first treatment choice reflected long-term treatment choice confirmed the presence of an association between PD and mortality. In conclusion, compared with HD, peritoneal dialysis appears to be associated with higher mortality among older patients, particularly among those with diabetes, even after controlling for a large number of risk factors for mortality, propensity scores to control for nonrandom treatment assignment, and center stratification.

Dialysis therapies for end-stage renal disease

End-stage renal disease (ESRD) has various causes that may differ according to country and racial group. Whatever the cause, unless the water, salt, electrolytes, and waste products excreted by normal kidneys are removed, their accumulation will result in death. Removal of these products can be variably achieved by either hemodialysis or peritoneal dialysis. The principles and outcomes of these techniques are described, as are their complications. It is important that these two different methods of treatment are not regarded as competitive, but are integrated, together with renal transplantation where appropriate, into the management of patients with ESRD to optimize both outcome and quality of life.

Survival and development of cardiovascular disease by modality of treatment in patients with end-stage renal disease

Patients undergoing dialysis are at high risk for cardiovascular disease (CVD). The aim of this study was to evaluate the influence of hemodialysis (HD) versus peritoneal dialysis (PD) on survival and the risk of developing de novo CVD. Of the 4191 patients with end-stage renal disease (ESRD) who started renal replacement treatment (RRT) in Lombardy between 1994 and 1997, 4064 (who were on dialysis 30 d after the start of RRT) were considered for survival analysis: 2772 were on HD (mean age 60.9 yr; 21.2% diabetic) and 1292 on PD (mean age 63.6 yr; 16% diabetic). The 3120 patients who were free of CVD at the start of RRT were included in the analysis of the risk of developing de novo CVD. HD and PD were compared by use of a Cox-regression proportional hazard model, stratified by diabetic status; the explanatory covariates were age and gender. The death rate was 13.3 per 100 patient-years (13.0 on HD and 13.9 on PD); 197 (6.3%) of the 3120 patients included in the CVD analysis developed de novo CVD (128 on HD and 69 on PD). After adjustment for age, gender, and established CVD and stratification by diabetic status, there was no significant between-treatment difference in 4-yr survival (relative risk [RR], 0.91; 95% confidence interval [CI], 0.79 to 1.06). The risk of de novo CVD did not differ significantly by treatment modality (RR, 1.06; 95% CI, 0.79 to 1.43). The risk of mortality and de novo CVD for new patients with ESRD assigned to HD or PD was similar in Lombardy in the period 1994 through 1997.