Peritoneal Dialysis–First Policy Made Successful: Perspectives and Actions

Exploring symptom clusters in Chinese patients with peritoneal dialysis: a network analysis

BACKGROUND

In recent years, the research on symptom management in peritoneal dialysis (PD) patients has shifted from a single symptom to symptom clusters and network analysis. This study collected and evaluated unpleasant symptoms in PD patients and explored groups of symptoms that may affect PD patients with a view to higher symptom management.

METHODS

The symptoms of PD patients were measured using the modified Dialysis Symptom Index. The symptom network and node characteristics were assessed by network analysis, and symptom clusters were explored by factor analysis.

RESULTS

In this study of 602 PD patients (mean age 47.8 ± 16.8 years, 47.34% male), most had less than 2 years of dialysis experience. Five symptom clusters were obtained from factor analysis, which were body symptom cluster, gastrointestinal symptom cluster, mood symptom cluster, sexual disorder symptom cluster, and skin-sleep symptom cluster. Itching and decreased interest in sex may be sentinel symptoms, and being tired or lack of energy and feeling anxious are core symptoms in PD patients.

CONCLUSIONS

This study emphasizes the importance of recognizing symptom clusters in PD patients for better symptom management. Five clusters were identified, with key symptoms including itching, decreased interest in sex, fatigue, and anxiety. Early intervention focused on these symptom clusters in PD patients holds promise for alleviating the burden of symptoms.

Dialysis for paediatric acute kidney injury in Cape Town, South Africa

BACKGROUND

Dialysis is lifesaving for acute kidney injury (AKI), but access is poor in less resourced settings. A "peritoneal dialysis (PD) first" policy for paediatric AKI is more feasible than haemodialysis in low-resource settings.

METHODS

Retrospective review of modalities and outcomes of children dialysed acutely at Red Cross War Memorial Children's Hospital between 1998 and 2020.

RESULTS

Of the 593 children with AKI who received dialysis, 463 (78.1%) received PD first. Median age was 9.0 (range 0.03-219.3; IQR 13.0-69.6) months; 57.6% were < 1 year old. Weights ranged from 0.9 to 2.0 kg (median 7.0 kg, IQR 3.0-16.0 kg); 38.6% were < 5 kg. PD was used more in younger children compared to extracorporeal dialysis (ECD), with median ages 6.4 (IQR 0.9-30.4) vs. 73.9 (IQR 17.5-113.9) months, respectively (p = 0.001). PD was performed with Seldinger soft catheters (n = 480/578, 83%), predominantly inserted by paediatricians at the bedside (n = 412/490, 84.1%). Complications occurred in 127/560 (22.7%) children receiving PD. Overall, 314/542 (57.8%) children survived. Survival was significantly lower in neonates (< 1 month old, 47.5%) and infants (1-12 months old, 49.2%) compared with older children (> 1 year old, 70.4%, p < 0.0001). Survival was superior in the ECD (75.4%) than in the PD group (55.6%, p = 0.002).

CONCLUSIONS

"PD First for Paediatric AKI" is a valuable therapeutic approach for children with AKI. It is feasible in low-resourced settings where bedside PD catheter insertion can be safely taught and is an acceptable dialysis modality, especially in settings where children with AKI would otherwise not survive.

Center Hemodialysis Versus Peritoneal Dialysis: A Cost-Utility Analysis

Introduction Kidney replacement therapy (KRT) is needed for patients with end-stage kidney disease. While it is clear that kidney transplantation remains the gold standard in KRT, data comparing the cost-utility of peritoneal dialysis (PD) and hemodialysis (HD) are scarce. No such analysis has been performed for German patients.  Methods We used aggregated data generated by the Short Form 36 Health Survey (SF-36) for quality of life and insurance claims to evaluate mortality and economic impact. Quality-adjusted life years (QALY) and cost-utility were calculated accordingly.  Results PD is superior to HD within all dimensions of the SF-36, both in terms of QALY and cost-utility. The difference in cost per QALY between the aggregated physical dimensions (€50,671.54 vs. €39,745.77) is greater than that of the aggregated mental dimensions (€31,638.75 vs. €25,287.63). However, there is considerable variability among patients.  Conclusion From a health-economic point of view, PD should be preferred over HD when deciding on the KRT modality for the patient. This is not reflected in current practice, though. However, interindividual differences and patient preferences should be considered in the decision.

Laparoscopic Techniques in Treatment of Inguinal Hernia in Patients with Peritoneal Dialysis: Experiences from 15 Cases

Objective: This study aimed to investigate the feasibility, efficacy, and safety of laparoscopic transabdominal preperitoneal (TAPP) repair in the treatment of inguinal hernia in patients on peritoneal dialysis, and the optimal timing for initiating postoperative peritoneal dialysis. Methods: We conducted a retrospective analysis of the clinical data pertaining to patients on peritoneal dialysis with inguinal hernias treated with TAPP repair in the First Affiliated Hospital of Shandong First Medical University from July 15, 2020 to December 15, 2022. Follow-up observations of the treatment effect were also analyzed. Results: A total of 15 patients underwent TAPP repair with success. Contralateral occult hernias were found in 3 cases intraoperatively and were treated simultaneously. During the operation, it was found that the peritoneal dialysis tube was completely wrapped in the omentum majus in 1 case and incompletely wrapped in 5 cases and was separated smoothly under laparoscopy. Conclusion: For patients on peritoneal dialysis with inguinal hernia, TAPP repair has the advantages of less trauma, simultaneous treatment of contralateral occult hernias, adjustment and fixation of peritoneal dialysis tubes, lower incision complication rates, and lower recurrence rates, compared with open surgery. With the gradual resumption of peritoneal dialysis 7 days postoperatively, TAPP repair can be performed safely and effectively in this population group; thus it is a procedure worth promoting.

A Service Reconfiguration Bundle for Expanding Access to Peritoneal Dialysis Including for Older Frailer Patients

INTRODUCTION

Rates of peritoneal dialysis (PD) have been traditionally low in Northern Ireland. With rising numbers of patients reaching end-stage kidney disease, PD is a more cost-effective treatment than haemodialysis and aligns with international goals to increase home-based dialysis options. The aim of our study was to highlight how a service reconfiguration bundle expanded access to PD in Northern Ireland.

METHODS

The service reconfiguration bundle consisted of the appointment of a surgical lead, a dedicated interventional radiologist for fluoroscopically guided PD catheter insertion, and a nephrology-led ultrasound-guided PD catheter insertion service in an area of particular need. All patients in Northern Ireland who had a PD catheter inserted in the year following service reconfigurations were included and prospectively followed up for one-year. Patient demographics, PD catheter insertion technique, setting of procedure, and outcome data were summarised.

RESULTS

The number of patients receiving PD catheter insertion doubled to 66 in the year following service reconfigurations. The range of approaches to PD catheter insertion (laparoscopic n = 41, percutaneous n = 24 and open n = 1) allowed a wide range of patients to benefit from PD. Six patients had emergency PD catheter insertion, with four receiving urgent or early start PD. Nearly half (48%, 29/60) of the PD catheters inserted electively were in smaller elective hubs rather than the regional unit. A total of 97% of patients successfully started PD. Patients who experienced percutaneous PD catheter insertion were older [median age 76 (range 37-88) vs. 56 (range 18-84), p < 0.0001] and had less previous abdominal surgery than patients who experienced laparoscopic PD catheter insertion (25%, 6/24 vs. 54%, 22/41, p = 0.05).

DISCUSSION

Through a service reconfiguration bundle, we were able to double our annual incident PD population. This study highlights how flexible models of service delivery introduced as a bundle can quickly deliver expanded access to PD and home therapy.

Impact of dialysis reimbursement policies on care outcomes in peritoneal dialysis patients

The number of treated end stage renal disease (ESRD) patients worldwide has rapidly grown. To prolong their lives ESRD patients require transplantation or dialysis treatment. Limited donor availability has caused most of the ESRD patients to rely on either hemodialysis (HD) or peritoneal dialysis (PD). Taiwan had the highest prevalence rate worldwide and sought to increase the PD utilization through a series of reimbursement incentives. This study evaluated the effect of those policy initiatives. A retrospective longitudinal study using a before-and-after analysis was conducted. ESRD patients initiating either PD or HD were identified from the entire population of Taiwan NHI's beneficiaries. PD patients, before and after the PD-encouraging initiatives, were matched through a propensity score technique, and the change in PD technical failure was analyzed. HD patients were also matched as the control group to assess the impact on PD mortality. The competing risk regression approach for survival analysis was adopted. The results indicate the increase in PD utilization during this period was also accompanied by increases in both technique failure and mortality. Since PD shifts more burden of care to patients, efforts to increase its utilization may require an increase in the education of providers and patients to benefit more effectively. It may also require an increase in staff to provide ongoing training and support as the policy unfolds.

Comparison of survival rates between incident hemodialysis patients and peritoneal dialysis patients: a 5-year prospective cohort study with propensity score matching

BACKGROUND

The effect of dialytic modality at the start of renal replacement therapy on prognosis is controversial.

METHODS

This multicenter, prospective cohort study included patients undergoing incident hemodialysis (HD) (n = 646) and peritoneal dialysis (PD) (n = 72). We excluded patients who lacked complete data for 3 months. One-to-one propensity score (PS) matching was performed before between-group comparison of survival rates (Kaplan-Meier method and log-rank test) and identification of factors affecting prognosis (Cox proportional-hazards regression analysis).

RESULTS

We enrolled 621 and 71 patients undergoing HD and PD, respectively (overall mean ± standard deviation age: 74 ± 13 years); 20% had cardiovascular disease (CVD). The median follow-up period was 41 (interquartile range 24-66) months. Following PS matching, we analyzed 65 patients undergoing HD and PD each. The 5-year overall survival rates did not differ between the groups (P = 0.97). The PD group exhibited a better CVD-related survival rate (P = 0.03). PD yielded adjusted hazard ratios for all-cause and CVD-related mortality of 0.99 (95% confidence interval [CI] 0.49-1.99, P = 0.97) and 3.92 (95% CI 1.05-14.7, P = 0.04), respectively. Age (P < 0.001) and the use of a central venous catheter (CVC) at dialytic initiation (P = 0.02) were independent risks for all-cause mortality; whereas, only the use of a CVC (P = 0.01) was an independent risk for CVD-related mortality.

CONCLUSION

Although no differences were observed in overall survival, CVD-related survival may be better with dialytic initiation with PD than with HD.

Nurse-based educational interventions in patients with peritoneal dialysis: A systematic review and meta-analysis

Background

Peritoneal dialysis (PD) is a major renal replacement therapy modality for patients with end-stage kidney disease (ESKD) worldwide. As poor self-care of PD patients could lead to serious complications, including peritonitis, exit-site infection, technique failure, and death; several nurse-based educational interventions have been introduced. However, these interventions varied and have been supported by small-scale studies so the effectiveness of nurse-based educational interventions on clinical outcomes of PD patients has been inconclusive.

Objectives

To evaluate the effectiveness of nurse-based education interventions in PD patients.

Design

A systematic review and meta-analysis of Randomized Controlled Trials (RCTs).

Methods

We performed a systematic search using PubMed, Embase, and CENTRAL up to December 31, 2021. Selection criteria included Randomized Controlled Trials (RCTs) relevant to nurse-based education interventions in ESKD patients with PD in the English language. The meta-analyses were conducted using a random-effects model to evaluate the summary outcomes of peritonitis, PD-related infection, mortality, transfer to hemodialysis, and quality of life (QoL).

Results

From 9,816 potential studies, 71 theme-related abstracts were selected for further full-text articles screening against eligibility criteria. As a result, eleven studies (1,506 PD patients in seven countries) were included in our systematic review. Of eleven studies, eight studies (1,363 PD patients in five countries) were included in the meta-analysis. Sleep QoL in the intervention group was statistically significantly higher than control (mean difference = 12.76, 95% confidence intervals 5.26-20.27). There was no difference between intervention and control groups on peritonitis, PD-related infection, HD transfer, and overall QoL.

Conclusions

Nurse-based educational interventions could help reduce some PD complications, of which only the sleep QoL showed statistically significant improvement. High-quality evidence on the nurse-based educational interventions was limited and more RCTs are needed to provide more robust outcomes.

Tweetable abstract

Nurse-based educational interventions showed promising sleep quality improvement and potential peritonitis risk reduction among PD patients.

Peritoneal dialysis first policy in Hong Kong for 35 years: Global impact

Peritoneal dialysis (PD) first policy has been established in Hong Kong since 1985. After 35 years of practice, the PD first policy in Hong Kong has influenced many countries around the world including governments, health ministries, nephrologists and renal nurses on the overall health policy structure and clinical practice in treating kidney failure patients using PD as an important dialysis modality. In 2021, the International Association of Chinese Nephrologists and the Hong Kong Society of Nephrology jointly held a symposium celebrating the 35 years of PD first policy in Hong Kong. In that symposium, experts and opinion leaders from around the world have shared their perspectives on how the PD first policy has grown and how it has affected PD and home dialysis practice globally. The advantages of PD during COVID-19 pandemic were highlighted and the use of telemedicine as an important adjunct was discussed in treating kidney failure patients to improve the overall quality of care. Barriers to PD and the need for sustainability of PD first policy were also emphasized. Overall, the knowledge awareness of PD as a home dialysis for patients, families, care providers and learners is a prerequisite for the success of PD first. A critical mass of PD regional hubs is needed for training and mentorship. Importantly, the alignment of policy and clinical goals are enablers of PD first program.

The Impact of Volume Overload on the Longitudinal Change of Adipose and Lean Tissue Mass in Incident Chinese Peritoneal Dialysis Patients

Patients treated with peritoneal dialysis (PD) experience complex body composition changes that are not adequately reflected by traditional anthropometric parameters. While lean and adipose tissue mass can be readily assessed by bioimpedance spectroscopy (BIS), there is concern about the potential confounding effect of volume overload on these measurements. This study aimed to assess the influence of fluid status (by echocardiography) on body composition parameters measured by BIS and to describe the longitudinal changes in adipose and lean tissue mass. We conducted a prospective observational study in a tertiary hospital. Incident Chinese PD patients underwent baseline echocardiography and repeated BIS measurements at baseline and 12 months later. Among 101 PD patients, lean tissue index (LTI) or fat tissue index (FTI) was not associated with echocardiographic parameters that reflected left ventricular filling pressure (surrogate of volume status). Sixty-eight patients with repeated BIS had a significant increase in body weight and FTI, while LTI remained similar. Gains in fat mass were significantly associated with muscle wasting (beta = −0.71, p < 0.0001). Moreover, progressive fluid accumulation independently predicted decrease in FTI (beta = −0.35, p < 0.0001) but not LTI. Body composition assessments by BIS were not affected by fluid status and should be considered as part of comprehensive nutrition assessment in PD patients.

Factors Affecting Selection of a Dialysis Modality in Elderly Patients With Chronic Kidney Disease: A Prospective Cohort Study in Korea

Background

We investigated factors associated with the selection of a dialysis modality for elderly patients compared to younger patients.

Methods

This study included 2,514 incident dialysis patients from a Korean multicenter prospective cohort. Multivariate logistic regression analyses were performed with demographic, socioeconomic, and clinical data to analyze factors associated with the chosen dialysis modality. Differences in these factors were compared between the elderly (≥65 years) and younger (<65 years) patients.

Results

Of the enrolled patients, 1,746 (69.5%) and 768 (30.6%) selected hemodialysis (HD) and peritoneal dialysis (PD), respectively. The percentage of PD was higher in younger patients than in elderly patients (37.1 vs. 16.9%, p < 0.001). Multivariate analysis showed that planned dialysis (p < 0.001), employment status (p < 0.001), and independent economic status (p = 0.048) were independent factors for selecting PD, whereas peripheral vascular disease (p = 0.038) and tumor (p = 0.010) were factors for selecting HD in the younger group. In the elderly group, planned dialysis (p < 0.001) and congestive heart failure (CHF; p = 0.002) were associated with choosing PD; however, tumor (p = 0.006) was associated with choosing HD. A two-way ANOVA showed that planned dialysis and CHF showed a significant interaction effect with age on modality selection.

Conclusions

As the age of patients with chronic kidney disease increased, HD was more frequently selected compared to PD. Dialysis planning and CHF interacted with age in selecting dialysis modalities in elderly patients. Elderly patients were less affected by socioeconomic status than younger patients.

Epidemiology of peritoneal dialysis outcomes

Peritoneal dialysis (PD) is an important home-based treatment for kidney failure and accounts for 11% of all dialysis and 9% of all kidney replacement therapy globally. Although PD is available in 81% of countries, this provision ranges from 96% in high-income countries to 32% in low-income countries. Compared with haemodialysis, PD has numerous potential advantages, including a simpler technique, greater feasibility of use in remote communities, generally lower cost, lesser need for trained staff, fewer management challenges during natural disasters, possibly better survival in the first few years, greater ability to travel, fewer dietary restrictions, better preservation of residual kidney function, greater treatment satisfaction, better quality of life, better outcomes following subsequent kidney transplantation, delayed need for vascular access (especially in small children), reduced need for erythropoiesis-stimulating agents, and lower risk of blood-borne virus infections and of SARS-CoV-2 infection. PD outcomes have been improving over time but with great variability, driven by individual and system-level inequities and by centre effects; this variation is exacerbated by a lack of standardized outcome definitions. Potential strategies for outcome improvement include enhanced standardization, monitoring and reporting of PD outcomes, and the implementation of continuous quality improvement programmes and of PD-specific interventions, such as incremental PD, the use of biocompatible PD solutions and remote PD monitoring.

The use of peritoneal dialysis (PD) can be advantageous compared with haemodialysis treatment, although several barriers limit its broad implementation. This review examines the epidemiology of peritoneal dialysis (PD) outcomes, including clinical, patient-reported and surrogate PD outcomes.

Peritoneal dialysis (PD) has distinct advantages compared with haemodialysis, including the convenience of home treatment, improved quality of life, technical simplicity, lesser need for trained staff, greater cost-effectiveness in most countries, improved equity of access to dialysis in resource-limited settings, and improved survival, particularly in the first few years of initiating therapy.

Important barriers can hamper PD utilization in low-income settings, including the high costs of PD fluids (owing to the inability to manufacture them locally and the exorbitant costs of their import), limited workforce availability and a practice culture that limits optimal PD use, often leading to suboptimal outcomes.

PD outcomes are highly variable around the world owing in part to the use of variable outcome definitions, a heterogeneous practice culture, the lack of standardized monitoring and reporting of quality indicators, and kidney failure care gaps (including health care workforce shortages, inadequate health care financing, suboptimal governance and a lack of good health care information systems).

Key outcomes include not only clinical outcomes (typically defined as medical outcomes based on clinician assessment or diagnosis) — for example, PD-related infections, technique survival, mechanical complications, hospitalizations and PD-related mortality — but also patient-reported outcomes. These outcomes are directly reported by patients and focus on how they function or feel, typically in relation to quality of life or symptoms; patient-reported outcomes are used less frequently than clinical outcomes in day-to-day routine care.

Supporting Shared Decision-Making and Home Dialysis in End-Stage Kidney Disease

It has been widely demonstrated that patient education and empowerment, especially involving shared treatment decisions, improve patient outcomes in chronic medical conditions, including chronic kidney disease requiring kidney replacement therapies. Accordingly, regulatory agencies in the US and worldwide recommend shared decision-making for finalizing one's choice of kidney replacement therapy. It is also recognized that the US needs to substantially increase home dialysis utilization to leverage its positive impacts on patient and healthcare cost-related outcomes. This perspective highlights how the routine clinical use of the recommended practice of shared decision-making can exist in synergy with the system's goal for increased home dialysis use. It introduces a pragmatic provider checklist, The Nephrologist's Shared Decision-Making Checklist, grounded in the relevant theories of shared decision-making, and, unlike some research assessments and extant tools, is easy to understand and implement in clinical practice. This qualitative Checklist can help providers ensure that they have co-constructed an SDM experience with the patient and involved caretakers, helping them benefit from the improved outcomes associated with SDM.

Excessive risk and poor outcome of hospital-acquired peritoneal dialysis-related peritonitis

Background

Peritoneal dialysis (PD) is a home-based renal replacement therapy. Since hospital staff are not often familiar with PD and its complications, PD patients may have an excess risk of developing PD-related peritonitis during hospital admission for unrelated reasons, and the outcome may be affected.

Methods

We reviewed 371 episodes of hospital-acquired PD-peritonitis in our center from 2000 to 2019. Their clinical characteristics and outcome were compared to 825 episodes that required hospital admission, and 1964 episodes that were treated as out-patient.

Result

Hospitalized PD patients had a significantly higher risk of developing peritonitis than out-patient ones (incident rate ratio 4.41, 95% confidence interval [CI] 3.95–4.91). Hospital-acquired peritonitis episodes were more commonly culture negative. Bacterial isolates from the hospital acquired episodes were more likely resistant to ceftazidime (p &lt; 0.0001) than the other groups. The primary response rate, complete cure rate, and overall mortality of the hospital-acquired episode were 66.6%, 62.0%, and 23.2% respectively, all worse than episodes that developed outside the hospital (p &lt; 0.0001 for all).

Conclusion

PD patients admitted to the hospital had a 4-fold increase in the risk of developing peritonitis. Hospital-acquired peritonitis episodes were more likely culture negative, be resistant to antibiotics. They also had a lower primary response rate, lower complete cure rate, and a higher mortality than episodes that developed outside hospital.

Living Well With Kidney Disease and Effective Symptom Management: Consensus Conference Proceedings

Chronic kidney disease (CKD) confers a high burden of uremic symptoms that may be underrecognized, underdiagnosed, and undertreated. Unpleasant symptoms, such as CKD-associated pruritus and emotional/psychological distress, often occur within symptom clusters, and treating 1 symptom may potentially alleviate other symptoms in that cluster. The Living Well with Kidney Disease and Effective Symptom Management Consensus Conference convened health experts and leaders of kidney advocacy groups and kidney networks worldwide to discuss the effects of unpleasant symptoms related to CKD on the health and well-being of those affected, and to consider strategies for optimal symptom management. Optimizing symptom management is a cornerstone of conservative and preservative management which aim to prevent or delay dialysis initiation. In persons with kidney dysfunction requiring dialysis (KDRD), incremental transition to dialysis and home dialysis modalities offer personalized approaches. KDRD is proposed as the preferred term given the negative connotations of "failure" as a kidney descriptor, and the success stories in CKD journeys. Engaging persons with CKD to identify and prioritize their personal values and individual needs must be central to ensure their active participation in CKD management, including KDRD. Person-centered communication and care are required to ensure diversity, equity, and inclusion; education/awareness that considers the health literacy of persons with CKD; and shared decision-making among the person with CKD, care partners, and providers. By putting the needs of people with CKD, including effective symptom management, at the center of their treatment, CKD can be optimally treated in a way that aligns with their goals.

Serum uric acid level and all-cause and cardiovascular mortality in peritoneal dialysis patients: A systematic review and dose-response meta-analysis of cohort studies

BACKGROUND

The association between serum uric acid (SUA) and all-cause and cardiovascular disease (CVD) mortality in peritoneal dialysis (PD) patients is controversial. Therefore, we aimed to determine the relationship between SUA and all-cause and CVD mortality in PD patients.

METHOD

Web of Science, EMBASE, PubMed and the Cochrane Library databases were searched from their inception to 7 April 2021. Effect estimates were presented as hazard ratios (HRs) with 95% confidence intervals (95% CIs) and pooled using random effects model.

RESULT

Thirteen cohort studies with 22418 patients were included in this systematic review, of which 9 were included in the meta-analysis. Before switching the reference group, pooled result for the highest SUA category was significantly greater than the median for all-cause mortality (HR = 2.41, 95% CI: 1.37-4.26). After switching the reference group, the highest SUA category did not demonstrate an increased all-cause (HR = 1.40, 95% CI: 0.95-2.05) or CVD (HR = 1.30, 95% CI: 0.72-2.34) mortality compared with the lowest SUA category. Dose-response analysis suggested a nonlinear association between SUA and all-cause mortality risk (Pnonlinearity = 0.002).

CONCLUSION

This meta-analysis didn't find the relationship between SUA levels and all-cause and CVD mortality risk in PD patients. More rigorously designed studies are warranted in the future.

Regression of Left Ventricular Hypertrophy in Patients Combined with Peritoneal Dialysis and Hemodialysis

METHODS

This retrospective study enrolled 58 patients at The Second Affiliated Hospital of Soochow University who switched from PD to PHD. Clinical data and echocardiographic examination results were collected. Data from the two groups with a normal distribution were compared with the paired t-test. A pvalue <0.05 (two-tailed) was considered statistically significant.

RESULTS

A total of 58 subjects were enrolled, including 46 males and 12 females, with a median age of 50.2 ± 11.1 (47-68) years. The mean duration of peritoneal dialysis was 67.2 ± 33.6 months. Before and after PHD, the ultrafiltration volume (p = 0.021) and hemoglobin (p = 0.001) were increased, while SBP (p = 0.002), DBP (p = 0.002), phosphorus (p < 0.001), and ESA dosage (p < 0.001) were decreased. Before and after combined dialysis (PHD), the incidence of LVH was 76.4% and 61.8%, respectively (p = 0.013), and LVMI decreased from 173.8 ± 86.2 g/m² to 160.6 ± 78.5 g/m² (p < 0.001).

CONCLUSION

Compared with PD alone, the combination of PD and HD resulted in regression of LVH and reduced LVMI.

Development of an instrument to assess self-management capacity of patients receiving peritoneal dialysis: CAPABLE

BACKGROUND

Treatment of kidney failure with peritoneal dialysis (PD) at home implies that the patient and/or their caregiver develop a series of skills and basic knowledge about this therapy. There is not a specific inventory of the patient's abilities to safely perform the PD procedure at home. The objective of this study was to describe the development of an instrument that allows measuring the self-management capacity of patients receiving PD, locating the performance areas that justify the need for intervention by a caregiver.

METHODS

This is a qualitative study developed in three phases: The first phase was the identification of performance areas through bibliographic search and validation of the results with focus groups of experts in PD. The second phase was the design of a system to measure self-management capacities. The third phase was a pilot test of the preliminary version of the instrument applied in 20 incident PD patients.

RESULTS

Three domains were identified to evaluate the fundamental components of self-management capacity: cognitive and sensory, each one evaluated with four items and motor domain evaluated with eight items. After applying the instrument, we found that 15 patients (75%) did not require support from the caregiver in any of the items. PD patients and nurses found the tool valuable, easy to understand and applicable in the early evaluation of a PD patient.

CONCLUSIONS

We developed an easy-to-administer instrument to measure the self-management capacity of patients receiving PD. This inventory could locate areas that require specific support from a caregiver. Planning an individualised and focused education and training process could result in better health outcomes.

Peritoneal dialysis: Status report in South and South East Asia

BACKGROUND

Peritoneal dialysis (PD) as a modality of kidney replacement therapy (KRT) is largely underutilized globally. We analyzed PD utilization, impact of economic status, projected growth and impact of state policy(s) on PD growth in South Asia and Southeast Asia (SA&SEA) region.

METHODS

The National Nephrology Societies of the region responded to a questionnaire on KRT practices. The responses were based on the latest registry data, acceptable community-based studies and societal perceptions. The representative countries were divided into high income and higher-middle income (HI & HMI) and low income and lower-middle income (LI & LMI) groups.

RESULTS

Data provided by 15 countries showed almost similar percentage of GDP as health expenditure (4%-7%). But there was a significant difference in per capita income (HI & HMI -US$ 28 129 vs. LI & LMI - US$ 1710.2) between the groups. Even after having no significant difference in monthly cost of haemodialysis (HD) and PD in LI & LMI countries, they have poorer PD utilization as compared to HI & HMI countries (3.4% vs. 10.1%); the reason being lack of formal training/incentives and time constraints for the nephrologist while lack of reimbursement and poor general awareness of modalities has been a snag for the patients. The region expects ≥10% PD growth in the near future. Hong Kong and Thailand with 'PD first' policy have the highest PD utilization.

CONCLUSION

Important deterrents to PD underutilization were lack of PD centric policies, lackadaisical patient/physician's attitude, lack of structured patient awareness programs, formal training programs and affordability.

Bioimpedance Guided Fluid Management in Peritoneal Dialysis: A Randomized Controlled Trial

BACKGROUND AND OBJECTIVES

Bioelectrical impedance analysis (BIA) devices can help assess volume overload in patients receiving maintenance peritoneal dialysis. However, the effects of BIA on the short-term hard end points of peritoneal dialysis lack consistency. This study aimed to test whether BIA-guided fluid management could improve short-term outcomes in patients on peritoneal dialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A single-center, open-labeled, randomized, controlled trial was conducted. Patients on prevalent peritoneal dialysis with volume overload were recruited from July 1, 2013 to March 30, 2014 and followed for 1 year in the initial protocol. All participants with volume overload were 1:1 randomized to the BIA-guided arm (BIA and traditional clinical methods) and control arm (only traditional clinical methods). The primary end point was all-cause mortality and secondary end points were cardiovascular disease mortality and technique survival.

RESULTS

A total of 240 patients (mean age, 49 years; men, 51%; diabetic, 21%, 120 per group) were enrolled. After 1-year follow-up, 11(5%) patients died (three in BIA versus eight in control) and 21 patients were permanently transferred to hemodialysis (eight in BIA versus 13 in control). The rate of extracellular water/total body water decline in the BIA group was significantly higher than that in the control group. The 1-year patient survival rates were 96% and 92% in BIA and control groups, respectively. No significant statistical differences were found between patients randomized to the BIA-guided or control arm in terms of patient survival, cardiovascular disease mortality, and technique survival (P>0.05).

CONCLUSIONS

Although BIA-guided fluid management improved the fluid overload status better than the traditional clinical method, no significant effect was found on 1-year patient survival and technique survival in patients on peritoneal dialysis.

Home-to-home dialysis transition: A 24-year single-centre experience

Home dialysis (peritoneal dialysis (PD) and home haemodialysis (HHD)) are ideal options for kidney replacement therapy (KRT). Occasionally, because of technique failure, patients are required to transition out of home dialysis, and the most common option tends to be to in-centre HD. There are few published studies on home-to-home transition (PD to HHD or HHD to PD) and dynamics during the transition period. We present a retrospective review of 28 patients who transitioned from a home-to-home dialysis modality at our centre over a 24-year period. We observed a total of 911 home dialysis patients with technique failure (826 PD patients and 85 HHD patients) with only 28 patients (3% of the total with technique failure) having successful home-to-home transition. During the transition period, 11 patients (39%) were hospitalized and 13 patients (46%) required variable periods of in-centre HD. After a median follow-up of 48 months following dialysis modality transition, four patients switched to in-centre HD permanently (home dialysis technique survival of 86% censored for death and kidney transplantation) and four patients died resulting in a patient survival of 86% (censored for switch to in-centre HD and transplantation). In our centre, home-to-home transition is a feasible strategy with comparable patient and technique survival. A significant proportion of patients switching from a home-to-home dialysis modality required variable intervals of hospitalization and in-centre HD during transitions. Future efforts should be directed towards assessment and home dialysis education during the entire process of dialysis transition.

Growing home dialysis: The Ontario Renal Network Home Dialysis Initiative 2012-2019

The Ontario Renal Network (ORN), a provincial government agency in Ontario, Canada, launched an initiative in 2012 to increase home dialysis use province-wide. The initiative included a new modality-based funding formula, a standard mandatory informatics system, targets for prevalent home dialysis rates, the development of a 'network' of renal programmes with commitment to home dialysis and a culture of accountability with frequent meetings between ORN and each renal programme leadership to review their results. It also included funding of home dialysis coordinators, encouragement and funding of assisted peritoneal dialysis (PD), and support for catheter insertion and urgent start PD. Between 2012 and 2017, home dialysis use rose from 21.9% to 26.5% and then between 2017 and 2019 stabilised at 26% to 26.5%. Over 7 years, the absolute number of people on home dialysis increased 40% from 2222 to 3105, while the number on facility haemodialysis grew 11% from 7935 to 8767. PD prevalence rose from 16.6% to 20.9%, a relative increase of 25%. The initiative showed that a sustained multifaceted approach can increase home dialysis utilisation.

Anemia Management in Peritoneal Dialysis: Perspectives From the Asia Pacific Region

Anemia is an important complication in patients with chronic kidney disease. Peritoneal dialysis (PD) is one of the most common modalities of kidney replacement therapy for patients with end-stage kidney disease. PD is particularly prevalent in the Asian Pacific region. Among the different countries and regions, including mainland China, Hong Kong, Japan, Malaysia, Singapore, South Korea, and Thailand, PD accounts for 2.8% to 74.6% of the dialysis population. In addition, 82% to 96% of the PD populations from these countries and regions are receiving erythropoiesis-stimulating agents (ESAs). Asian Pacific countries and regions follow the latest KDIGO (Kidney Disease: Improving Global Outcomes) guidelines for the initiation of treatment of anemia in PD patients. The types of ESAs commonly used include shorter-acting (epoetin alfa and beta) and longer-acting agents, including darbepoetin alfa or methoxy polyethylene glycol-epoetin beta. The most commonly used ESAs in Mainland China, Malaysia, Singapore, and Thailand are the shorter-acting agents, whereas in Hong Kong, Japan, and South Korea, longer-acting ESAs are most common. Oral iron therapy is still the most commonly used iron supplement. The route and dosage of iron administration in PD patients requires more research studies. With the introduction of oral hypoxia-inducible factor prolyl hydroxylase inhibitors into clinical use, the landscape of treatment of anemia in the PD population in the Asia Pacific region may change in the coming years.

Perceptions of chronic kidney disease among at-risk adults in rural Guatemala

This qualitative study explores perceptions of chronic kidney disease (CKD) among adults with abnormal estimated glomerular filtration rate (eGFR) in Guatemala, where the burden of CKD is rising. Qualitative semi-structured interviews were conducted with 39 individuals screened for CKD and found to have abnormal eGFR (defined as <90 mL/min/1.73 m2, per Kidney Disease Improving Global Outcomes [KDIGO] guidelines). Interviews occurred in participants' homes in Spanish or Kaqchikel Mayan. Interview notes were coded for dominant themes through an inductive approach. Interviewees had limited awareness of diabetes and hypertension as CKD risk factors, but appreciated the progressive nature of the disease. While most reported willingness to pursue renal replacement therapies, if necessary, they anticipated economic and geographic barriers. Public health interventions should focus on the association between diabetes, hypertension, and CKD. Improvement of primary care and screening infrastructure is imperative in CKD prevention in low- and middle-income countries (LMICs).

Tension-free mesh repair of inguinal hernia in patients on continuous ambulatory peritoneal dialysis

BACKGROUND

Peritoneal dialysis (PD) is the first-line renal replacement therapy for end-stage renal failure patients in Hong Kong. Abdominal wall hernia is a common mechanical complication of PD, and early surgical repair has been advocated to reduce complications. This study aims to review the outcomes of tension-free mesh repair of inguinal hernia in PD patients.

METHODS

All PD patients who underwent elective repair of inguinal hernia from 2009 to 2015 were identified from a single centre for retrospective analysis. Primary outcomes included surgical complications, perioperative dialysis technique and recurrence.

RESULTS

Twenty-one patients with a total of 26 inguinal hernia repairs were included in this 7-year retrospective study. All were males, and the mean age was 68 ± 10 years. Diabetic nephropathy (n = 9, 42.9%) and glomerulonephritis (n = 7, 33.3%) were the two most common causes of renal failure. All hernias were detected after the initiation of PD, and the mean duration of PD to hernia detection was 16 months (range 1-65 months). Lichtenstein open mesh repair was performed in all patients. Complications included seroma (n = 3, 11.5%) and ischaemic orchitis (n = 1, 3.8%). There were no mesh infection or recurrence. Twenty patients (95.2%) received intermittent peritoneal dialysis post-operatively and returned to continuous ambulatory PD in 15 to 30 days. Only one patient (4.8%) required bridging haemodialysis due to Tenckhoff catheter blockage.

CONCLUSIONS

Tension-free mesh repair is associated with low morbidity and low recurrence rates in PD patients. Timely management and close collaboration with renal physicians are essential to continue PD after repair.

The Cost-Effectiveness of Kidney Replacement Therapy Modalities: A Systematic Review of Full Economic Evaluations

BACKGROUND

Kidney replacement therapy (KRT) is a lifesaving but costly treatment for patients with end-stage kidney disease (ESKD). The objective of this study was to review full economic evaluations comparing KRT modalities specified as hemodialysis (HD), peritoneal dialysis (PD), and kidney transplantation (KT) for patients with ESKD.

METHODS

We conducted a systematic review of the literature from PubMed, Embase, EconLit (EBSCO), Web of Science, Cochrane Library, National Health Service Economic Evaluation Database (NHS EED), Centre for Reviews and Dissemination (CRD) Database of Abstracts of Reviews of Effects (DARE), and CRD Health Technology Assessment Database from inception until 5 January 2020. Full economic evaluations were included if they compared three forms of KRT specified as PD, HD, and KT. The reporting quality of included studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.

RESULTS

Ten studies were identified in the review. The majority of the studies were model-based evaluations and included a cost-utility analysis. Four studies were conducted from a public healthcare perspective, three from a societal perspective, and three from a third-party payer perspective. None of the studies adequately addressed all the applicable items of the CHEERS checklist. The most infrequently reported items were characterizing heterogeneity, target population, and characterizing uncertainty. There is a lack of studies that conduct from a societal perspective and take into account characterizing heterogeneity. All included studies indicate that KT is the most cost-effective KRT modality, with either a dominant position over HD and PD or an incremental cost-effectiveness ratio well below the accepted willingness-to-pay threshold. The majority of studies suggest that PD is less costly and offers comparable or better health outcomes than HD.

CONCLUSIONS

Our systematic review suggests that KT is the most cost-effective KRT modality, but there is no firm conclusion about the cost-effectiveness of HD and PD. Further economic evaluations can be conducted from a societal perspective and detail the evidence for subsets of patients with different characteristics.

A Mixed Methods Study of Symptom Experience in Patients With End-Stage Renal Disease

BACKGROUND

Patients with end-stage renal disease receiving dialysis experience a significant symptom burden. Identifying factors associated with this burden may improve symptom management. However, specific evidence about patients' experiences is lacking.

OBJECTIVES

The aim of this study was to explore factors that are associated with patients' symptom experiences.

METHODS

The convergent parallel mixed methods design was used. In the quantitative component, the Dialysis Symptom Index was used to assess the symptom burden of 271 participants to examine its associations with patient characteristics using correlation coefficients and multivariate regression analyses. In the qualitative component, associated factors reported by 10 participants were identified through semistructured interviews using content analysis. Assessments were conducted at enrollment, 6 months, and 12 months. After separate data analyses, findings were integrated using side-by-side comparison and joint display.

RESULTS

Several significant associations were identified between patient characteristics and symptom burden, and the participants described four categories of factors (i.e., treatment related, pathophysiological, situational, dietary) associated with a higher symptom burden during their interviews. Across both components of this study, three factors were consistent (i.e., employment, hyperphosphatemia, anemia). Participants described several factors not reported previously.

DISCUSSION

This study explored subjective and objective factors influencing the symptom experiences of patients with end-stage renal disease using a mixed methods design. These risk factors can be used to identify high-risk patients. Our findings suggest that participants relied on laboratory results and treatments to explain their symptom experiences. These findings suggest that assessment of both subjective and objective factors is needed to explore patients' symptom experiences.

Analysis of risk factors and construction of prediction model of drop out from peritoneal dialysis

This study is to investigate the risk factors for the drop out from peritoneal dialysis.We retrospectively analyzed patients who underwent catheterization between January 1, 2009 and September 30, 2019. The follow-up period ended on November 30, 2019. End point events were the cessation of peritoneal dialysis, including death, conversion to hemodialysis, and kidney transplantation. Kaplan-Meier method was used to analyze peritoneal dialysis curve. Significant factors were included in the multivariate Cox proportional hazards model. Calibration curve was plotted.A total of 377 patients were included in this study. The dropout rate of peritoneal dialysis was 41.38%. The main drop out reason was conversion to hemodialysis, accounting for 41.67% of the total number of drop out, followed by kidney transplantation (28.21%) and death (25%). According to multivariable Cox proportional hazards model analysis, the medium education level (hazard ratio (HR): 2.53, 95% confidence interval (CI): 1.08-5.91, P = .03), high education level (HR: 2.47, 95% CI: 1.03-5.93, P = .04), diabetes (HR: 1.87, 95% CI: 1.24-2.83, P < .03), hypertension (HR: 2.40, 95% CI: 1.64-3.51, P < .01), repeated peritonitis (HR: 5.18, 95% CI: 3.04-8.80, P < .01), and repeated chest complications (HR: 4.98, 95% CI: 2.79-8.89, P < .01) were independent risk factors for dropping out from peritoneal dialysis, while the number of hospitalizations after catheterization (HR: 0.94, 95% CI: 0.89-0.98, P = .01) was protective factor for maintenance of peritoneal dialysis. The C index of the prediction model was 0.74.Higher education level, diabetes, hypertension, repeated peritonitis, and repeated chest complications were the risk factors of dropping out from peritoneal dialysis, while higher number of hospitalizations after catheterization was a protective factor for the maintenance of peritoneal dialysis. The nomogram could predict the probability of dropping out from peritoneal dialysis.

Inguinal hernias in patients on continuous ambulatory peritoneal dialysis: is tension-free mesh repair feasible?

Background

Continuous ambulatory peritoneal dialysis (CAPD), which often causes a common complication such as abdominal wall hernia, is a prevalent alternative therapy for end-stage renal failure patients. However, relevant studies are somewhat rare, and the peritoneal dialysis (PD) protocol during the perioperative period is still controversial. The aim of this study was to evaluate the effectiveness and perioperative management of tension-free mesh repair for inguinal hernias in CAPD patients.

Methods

Between January 2013 and December 2019, 18 CAPD patients with 20 inguinal hernias who underwent tension-free mesh repair were retrospectively analyzed. Data on demographics, perioperative features, the perioperative dialysis protocol and surgical complications were collected and assessed.

Results

All hernias were diagnosed after the start of CAPD, and the median duration from PD onset to hernia formation was 16 months (2–61 months). All patients underwent successful tension-free mesh repair, including 17 Lichtenstein and 3 anterior Kugel procedures. The median operation time was 62.5 min, and the median postoperative hospital stay was 3 days. Fifteen patients received low-exchange volumes and high-frequency exchanges from 1 to 3 days after surgery for 2 weeks with gradual resumption of the original CAPD regimen within 4 weeks. Complications included seroma (n = 2) and hematoma (n = 1). No wound or mesh infection or recurrence occurred during the follow-up period.

Conclusions

Tension-free mesh repair is safe and feasible for inguinal hernias in CAPD patients, The Lichtenstein mesh repair should be the first choice, and anterior Kugel repair may be considered an effective procedure. Bridging hemodialysis seems unnecessary except for emergency surgery.

Ethical challenges in nephrology: a call for action

The American Society of Nephrology, the European Renal Association-European Dialysis and Transplant Association and the International Society of Nephrology Joint Working Group on Ethical Issues in Nephrology have identified ten broad areas of ethical concern as priority challenges that require collaborative action. Here, we describe these challenges - equity in access to kidney failure care, avoiding futile dialysis, reducing dialysis costs, shared decision-making in kidney failure care, living donor risk evaluation and decision-making, priority setting in kidney disease prevention and care, the ethical implications of genetic kidney diseases, responsible advocacy for kidney health and management of conflicts of interest - with the aim of highlighting the need for ethical analysis of specific issues, as well as for the development of tools and training to support clinicians who treat patients with kidney disease in practising ethically and contributing to ethical policy-making.

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

Background

Kidney transplantation offers the best potential for full rehabilitation in patients with end-stage kidney disease who are treated with dialysis. However, due to organ shortage which is a universal phenomenon, most patients need to be maintained on a period of dialysis therapy before the prospect of transplantation. Peritoneal dialysis (PD) could be an ideal form of renal replacement therapy due to its favorable profile toward preservation of residual renal function, patient survival, lower overall burden on cardiovascular morbidity and infection risks.

Methods

With extensive experience in PD therapy from Hong Kong where PD-first is a mandatory health policy, we reviewed the literature and present current evidence that favors PD as an optimal form of bridging renal replacement therapy prior to kidney transplantation.

Results

PD provides a viable and advantageous form of renal reaplcement particularly in terms of preservation of residual renal function, patient survival and quality of life, and cost among many other factors. Potential misconceptions that PD-related peritonitis and dialysis inadequacy are potentially deterrent factors for initiating PD therapy are clarified.

Conclusion

PD is a practical and noninferior form of renal replacement that serves as an ideal bridge from conservative therapy to kidney transplantation.

Asiaticoside inhibits TGF-β1-induced mesothelial-mesenchymal transition and oxidative stress via the Nrf2/HO-1 signaling pathway in the human peritoneal mesothelial cell line HMrSV5

Background

Peritoneal fibrosis (PF) is a frequent complication caused by peritoneal dialysis (PD). Peritoneal mesothelial cells (PMCs), the first barrier of the peritoneum, play an important role in maintaining structure and function in the peritoneum during PD. Mesothelial-mesenchymal transition (MMT) and oxidative stress of PMCs are two key processes of PF.

Purpose

To elucidate the efficacy and possible mechanism of asiaticoside inhibition of MMT and ROS generation in TGF-β1-induced PF in human peritoneal mesothelial cells (HPMCs).

Methods

MMT and ROS generation of HPMCs were induced by TGF-β1. To explain the anti-MMT and antioxidant role of asiaticoside, varied doses of asiaticoside, oxygen radical scavenger (NAC), TGF-β receptor kinase inhibitor (LY2109761) and Nrf2 inhibitor (ML385) were used separately. Immunoblots were used to detect the expression of signaling associated proteins. DCFH-DA was used to detect the generation of ROS. Transwell migration assay and wound healing assay were used to verify the capacity of asiaticoside to inhibit MMT. Immunofluorescence assay was performed to observe the subcellular translocation of Nrf2 and expression of HO-1.

Results

Asiaticoside inhibited TGF-β1-induced MMT and suppressed Smad signaling in a dose-dependent manner. Migration and invasion activities of HPMCs were decreased by asiaticoside. Asiaticoside decreased TGF-β1-induced ROS, especially in a high dose (150 μM) for 6 h. Furthermore, ML385 partly abolished the inhibitory effect of asiaticoside on MMT, ROS and p-Smad2/3.

Conclusions

Asiaticoside inhibited the TGF-β1-induced MMT and ROS via Nrf2 activation, thus protecting the peritoneal membrane and preventing PF.

Foreign Perspective on Achieving a Successful Peritoneal Dialysis-First Program

Podcast

This article contains a podcast at https://www.asn-online.org/media/podcast/K360/2020_07_30_KID0000712019.mp3.

Comparison of Cardiovascular Outcomes by Dialysis Modality: A Systematic Review and Meta-Analysis

Debates exist regarding the merit of starting one dialysis modality over the other for improved cardiovascular outcomes. Five previously published prospective and retrospective cohort studies have reported inconsistent conclusions on this topic. The aim of this systematic review and meta-analysis is to evaluate the influence initiation of hemodialysis (HD) vs peritoneal dialysis (PD) may have on the relative risk (RR) of subsequent development of adverse cardiovascular events (ACVE) in patients with end-stage renal disease (ESRD). Of the 518 records identified, 5 cohort studies, assessing a total of 47,062 patients were included in the meta-analysis. With regard to the subsequent development of ACVE following initiation on the different dialysis modalities, the pooled RR was found to be non-significant. Peritoneal dialysis is a suitable and cost-effective alternative to HD for ESRD patients at risk of cardiovascular disease.

Capturing and monitoring global differences in untreated and treated end-stage kidney disease, kidney replacement therapy modality, and outcomes

A large gap between the number of people with end-stage kidney disease (ESKD) who received kidney replacement therapy (KRT) and those who needed it has been recently identified, and it is estimated that approximately one-half to three-quarters of all people with ESKD in the world may have died prematurely because they could not receive KRT. This estimate is aligned with a previous report that estimated that >3 million people in the world died each year because they could not access KRT. This review discusses the reasons for the differences in treated and untreated ESKD and KRT modalities and outcomes and presents strategies to close the global KRT gap by establishing robust health information systems to guide resource allocation to areas of need, inform KRT service planning, enable policy development, and monitor KRT health outcomes.

Peritoneal Dialysis: A Scoping Review of Strategies to Maximize pd Utilization

The percentage of end-stage renal disease (ESRD) patients treated with peritoneal dialysis (PD) has declined in many countries since the mid-1990s. Barriers to PD have been reviewed extensively in the literature, but evidence about strategies to address these barriers and maximize the safe and effective use of PD is lacking. We therefore decided to conduct a scoping review identifying strategies to maximize PD use in adults with ESRD. Our search strategy included the following online databases: MEDLINE (OVID), EMBASE, PubMed, Cochrane Controlled Trials Register, Current Controlled Trials, and Cochrane Database of Systematic Reviews for articles published from 1974 to November 2013. Experts in the field were contacted for information about other ongoing or unpublished studies. A complementary search was conducted in the gray literature. Websites of national, provincial or regional agencies were searched for documents regarding policies surrounding the use of PD. Individual dialysis centers need to identify barriers to increasing PD in their program and direct targeted strategies to maximize PD utilization. Our review highlights some effective strategies that may be used. Our review also highlights the need for further research into strategies to maximize PD utilization.

Lifetime cost-effectiveness analysis of first-line dialysis modalities for patients with end-stage renal disease under peritoneal dialysis first policy

BACKGROUND

This study aimed to determine the lifetime cost-effectiveness of first-line dialysis modalities for end-stage renal disease (ESRD) patients under the "Peritoneal Dialysis First" policy.

METHODS

Lifetime cost-effectiveness analyses from both healthcare provider and societal perspectives were performed using Markov modelling by simulating at age 60. Empirical data on costs and health utility scores collected from our studies were combined with published data on health state transitions and survival data to estimate the lifetime cost, quality-adjusted life-years (QALYs) and cost-effectiveness of three competing dialysis modalities: peritoneal dialysis (PD), hospital-based haemodialysis (HD) and nocturnal home HD.

RESULTS

For cost-effectiveness analysis over a lifetime horizon from the perspective of healthcare provider, hospital-based HD group (lifetime cost USD$142,389; 6.58 QALYs) was dominated by the PD group (USD$76,915; 7.13 QALYs). Home-based HD had the highest effectiveness (8.37 QALYs) but with higher cost (USD$97,917) than the PD group. The incremental cost-effectiveness ratio (ICER) was USD$16,934 per QALY gained for home-based HD over PD. From the societal perspective, the results were similar and the ICER was USD$1195 per QALY gained for home-based HD over PD. Both ICERs fell within the acceptable thresholds. Changes in model parameters via sensitivity analyses had a minimal impact on ICER values.

CONCLUSIONS

This study assessed the cost-effectiveness of dialysis modalities and service delivery models for ESRD patients under "Peritoneal Dialysis First" policy. For both healthcare provider and societal perspectives, PD as first-line dialysis modality was cost-saving relative to hospital-based HD, supporting the existing PD First or favoured policy. When compared with PD, Nocturnal home Home-based HD was considered a cost-effective first-line dialysis modality for ESRD patients.

Dialysis Care and Dialysis Funding in Asia

Asia is the largest and most populated continent in the world, with a high burden of kidney failure. In this Policy Forum article, we explore dialysis care and dialysis funding in 17 countries in Asia, describing conditions in both developed and developing nations across the region. In 13 of the 17 countries surveyed, diabetes is the most common cause of kidney failure. Due to great variation in gross domestic product per capita across Asian countries, disparities in the provision of kidney replacement therapy (KRT) exist both within and between countries. A number of Asian nations have satisfactory access to KRT and have comprehensive KRT registries to help inform practices, but some do not, particularly among low- and low-to-middle-income countries. Given these differences, we describe the economic status, burden of kidney failure, and cost of KRT across the different modalities to both governments and patients and how changes in health policy over time affect outcomes. Emerging trends suggest that more affluent nations and those with universal health care or access to insurance have much higher prevalent dialysis and transplantation rates, while in less affluent nations, dialysis access may be limited and when available, provided less frequently than optimal. These trends are also reflected by an association between nephrologist prevalence and individual nations' incomes and a disparity in the number of nephrologists per million population and per thousand KRT patients.

Peritoneal Dialysis Patient Outcomes under the Medicare Expanded Dialysis Prospective Payment System

BACKGROUND AND OBJECTIVES

Peritoneal dialysis (PD) use increased in the United States with the introduction of a new Medicare prospective payment system in January 2011 that likely reduced financial disincentives for facility use of this home therapy. The expansion of PD to a broader population and facilities having less PD experience may have implications for patient outcomes. We assessed the impact of PD expansion on PD discontinuation and patient mortality.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A prospective cohort study was conducted of patients treated with PD at 90 days of ESKD. Patients were grouped by study start date relative to the Medicare payment reform: prereform (July 1, 2008 to December 31, 2009; n=10,585), interim (January 1, 2010 to December 31, 2010; n=7832), and reform period (January 1, 2011 to December 31, 2012; n=18,742). Patient characteristics and facility PD experience were compared at baseline (day 91 of ESKD). Patients were followed for 3 years for the major outcomes of PD discontinuation and mortality using Cox proportional hazards models.

RESULTS

Patient characteristics, including age, sex, race, ethnicity, rurality, cause of ESKD, and comorbidity, were similar or showed small changes across the three study periods. There was an increasing tendency for patients on PD to be treated in facilities with less PD experience (from 34% during the prereform period being treated in facilities averaging <14 patients on PD per year to 44% in the reform period). Patients treated in facilities with less PD experience had a higher rate of PD discontinuation than patients treated in facilities with the most experience (hazard ratio [HR], 1.16; 95% confidence interval [95% CI], 1.10 to 1.23 for the first versus fifth quintile of PD experience). Nevertheless, the risk of PD discontinuation fell during the late interim period (HR, 0.88; 95% CI, 0.82 to 0.95) and most of the reform period (from HR, 0.85; 95% CI, 0.79 to 0.91 to HR, 0.94; 95% CI, 0.87 to 1.01). Mortality risk was stable across the three study periods.

CONCLUSIONS

In the context of expanding PD use and declining facility PD experience, the risk of PD discontinuation fell, and there was no adverse effect on mortality.

PODCAST

This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2019_09_12_CJN01610219.mp3.

Cost Controversies of a "Home Dialysis First" Policy

Purpose of review

Kidney Failure is highly prevalent and uses a disproportionate amount of health care funding. In Canada (excluding Quebec), 37 647 people were living with kidney failure in 2016. The single-payer Canadian health care system spends approximately 1.2% of their annual budget on kidney failure. In 2016, 58.4% of patients with kidney failure in Canada (excluding Quebec) were on dialysis as opposed to living with a functioning kidney transplant. Home dialysis modalities including peritoneal dialysis (PD) and home hemodialysis (HD) were used by 18.9% and 4.7% of these patients, respectively. In-center HD and home dialysis (PD and home HD) are often considered equally efficacious and have similar impacts on quality of life. Despite cost minimization analyses suggesting that home dialysis offers cost savings over in-center HD, there has been a slow uptake of home dialysis in developed nations over time, suggesting that controversies and barriers to implementation currently exist. The primary objective of this health policy briefing article is to introduce and address some of the major controversies surrounding the cost effectiveness in supporting advocacy for a "Home Dialysis First" policy with a primary focus on single-payer systems in a developed nation such as Canada.

Sources of information

Canadian Agency for Drugs and Technologies in Health (CADTH), Canadian and US epidemiologic databases, national/international conference presentations, primary literature review, and discussion with experts within the field of home dialysis.

Methods

We have conducted a focused primary literature review alongside individuals with expertise in the field of home dialysis to discuss the cost controversies surrounding the implementation of a "Home Dialysis First" policy.

Key findings

First, the primary literature is limited to mostly observational studies which are highly variable in study design and content. Local economic assessments, however, have provided convincing data for home dialysis cost savings in Canada. Second, the cost of delivering dialysis differs significantly throughout the world, explained by differing costs of labor and supplies in developing nations. Third, the indirect patient costs of water, energy, and home modifications are often barriers to implementation and may be overcome by introducing cost reimbursement programs. Fourth, home dialysis requires upfront training costs. We explore the impact of premature switches from home dialysis to in-center HD or a functioning kidney transplant on overall cost savings. Fifth, we discuss the effect of physician financial incentives and program funding on the uptake of home dialysis. Finally, we introduce the controversial topic of comparing the societal value of freedom of modality choice against the societal cost savings of a "Home Dialysis First" policy.

Limitations

Narrative reviews, due to their inherently reduced methodological quality in comparison with systematic reviews, may expose our collected literature to selection bias. We have attempted to compose a diverse collection of available literature alongside consensus expertise to provide a fair and concise review of home dialysis cost controversies.

Implications

Implementation of a "Home Dialysis First" policy would be a disruptive change to kidney failure care in Canada. To make informed policy decisions, we should recognize the cost savings associated with home dialysis in developed nations, the significance of patient-borne costs as a barrier to implementation, the impact of training costs and early modality switching in home dialysis, the lack of evidence regarding physician financial incentives, and the importance of program funding. Ultimately, we must consider the societal value of freedom of patient modality choice in comparison with the potential cost savings of a "Home Dialysis First" policy.

Intermittent Oral Dosing of Roxadustat in Peritoneal Dialysis Chronic Kidney Disease Patients with Anemia: A Randomized, Phase 3, Multicenter, Open-Label Study

Roxadustat is an oral hypoxia-inducible factor prolyl hydroxylase inhibitor developed to treat anemia in chronic kidney disease (CKD) patients. This Phase 3, randomized, open-label, 24-week study investigated the efficacy and safety of roxadustat in Japanese CKD patients with anemia on peritoneal dialysis (PD) who were previously treated or not treated with erythropoiesis stimulating agents (ESAs). Patients not previously receiving ESA (ESA-Naïve group) were randomized to roxadustat at a starting dose of 50 or 70 mg three times weekly; patients previously receiving ESA (ESA-Converted group) switched from ESA to roxadustat 70 or 100 mg three times weekly depending on the prior ESA dose. Outcomes included maintenance rate of average hemoglobin (Hb) level within 10-12 g/dL at weeks 18-24, cumulative response rate at end of treatment (Hb thresholds, 10.0 g/dL or 10.5 g/dL; Hb increase, ≥1.0 g/dL), and average Hb levels at weeks 18-24. Safety was assessed by occurrence of treatment-emergent adverse events (TEAEs). Fifty-six patients were enrolled (ESA-Naïve, n = 13; ESA-Converted, n = 43). Maintenance rates (weeks 18-24) were 92.3% (95% CI: 64.0-99.8; ESA-Naïve) and 74.4% (95% CI: 58.8-86.5; ESA-Converted). Cumulative response rate was 100.0% in the ESA-Naïve group. Average Hb levels (weeks 18-24) were 11.05 g/dL (95% CI: 10.67-11.42; ESA-Naïve) and 10.93 g/dL (95% CI: 10.73-11.13; ESA-Converted). Common TEAEs included nasopharyngitis and back pain. Roxadustat was well tolerated and effective in maintaining target Hb levels in CKD patients on PD who were previously treated or not treated with ESA.

Patient Perspectives on Renal Replacement Therapy Modality Choice: A Multicenter Questionnaire Study on Bioethical Dimensions

Background:Peritoneal dialysis (PD) incidence and prevalence in Germany are low compared with hemodialysis (HD), an underachievement with multifactorial causes. Patient perspectives on renal replacement therapy (RRT) choice play a growing role in research. To date, and to the best of our knowledge, the importance of bioethical dimensions in the context of RRT choice has not been analyzed. The aim of this multicenter questionnaire study was to delineate differences in patient perspectives of PD vs HD in terms of bioethical dimensions, thus helping nephrologists target potential PD candidates more efficiently.Methods:A total of 121 stable outpatients from 2 tertiary care hospitals and 4 dialysis clinics were surveyed for bioethical dimensions ("autonomy," "beneficence," "non-maleficence," "justice," and "trust") with ranking and Likert scale items. Inclusion criteria were RRT > 3 months, age ≥ 18 years, and sufficient cognitive and language skills.Results:A surprisingly high percentage of patients felt excluded from the RRT choice process. Peritoneal dialysis patients were more critical of RRT. They used more versatile information sources on RRT, whereas HD patients were mainly informed by their nephrologist. Peritoneal dialysis patients felt more often dissatisfied with RRT than HD patients and had less trust in their co-patients. However, PD patients felt less autonomy impairment regarding body integrity, fluid balance, and dialysis in general.Conclusions:Our study demonstrates that PD patients showed more scrutiny of their situation as patients, especially their co-patients. Their treatment empowered them toward feeling more autonomous than HD patients. These new insights into patient perspectives on RRT choice might facilitate modality choice for nephrologists.

Cost Effectiveness of Dialysis Modalities: A Systematic Review of Economic Evaluations

BACKGROUND AND OBJECTIVE

The economic burden of providing maintenance dialysis to those with end-stage kidney disease continues to increase. Home dialysis, including both haemodialysis and peritoneal dialysis, is commonly assumed to be more cost effective than facility dialysis, with some countries adopting a home-first policy in an attempt to reduce costs. However, the cost effectiveness of this approach is uncertain. The aim of this study is to review all published cost-effectiveness analyses comparing all alternative dialysis modalities for people with end-stage kidney disease.

METHODS

We conducted a systematic review of MEDLINE, the National Health Service Economic Evaluation Database, and Health Technology Assessment Database from the Centre of Reviews and Dissemination, The Cochrane Library and Econlit from January 2000 to December 2017. Published economic evaluations were included if they provided comparative information on the costs and health outcomes of alternative dialysis modalities.

RESULTS

The review identified 16 economic evaluations comparing dialysis modalities from both high- and low-income countries. The majority (69%) were undertaken solely from the perspective of the payer or service provider, 14 (88%) included a cost-utility analysis and eight (50%) were modelled evaluations. The studies addressed costs and health outcomes of multiple dialysis modalities, with many reporting average cost effectiveness rather than incremental cost effectiveness. Almost all evaluations suggest home dialysis to be less costly and to offer comparable or better health outcomes than in-centre haemodialysis. However, the quality-of-life benefit for each modality was poorly defined and inconsistent in terms of magnitude and direction of differences between modalities and across studies. Other issues include exclusion of competing modalities and use of arbitrary assumptions with regard to the mix of modalities.

CONCLUSIONS

The ability to identify the mix of dialysis modalities that provides best outcomes for patients and health budgets is uncertain particularly given the lack of societal perspectives and inconsistencies between published studies.

Transition Between Different Renal Replacement Modalities: Gaps in Knowledge and Care-The Integrated Research Initiative

Patients with end-stage kidney disease (ESKD) have different options to replace the function of their failing kidneys. The "integrated care" model considers treatment pathways rather than individual renal replacement therapy (RRT) techniques. In such a paradigm, the optimal strategy to plan and enact transitions between the different modalities is very relevant, but so far, only limited data on transitions have been published. Perspectives of patients, caregivers, and health professionals on the process of transitioning are even less well documented. Available literature suggests that poor coordination causes significant morbidity and mortality.This review briefly provides the background, development, and scope of the INTErnational Group Research Assessing Transition Effects in Dialysis (INTEGRATED) initiative. We summarize the literature on the transition between different RRT modalities. Further, we present an international research plan to quantify the epidemiology and to assess the qualitative aspects of transition between different modalities.

Direct and indirect costs of end-stage renal disease patients in the first and second years after initiation of nocturnal home haemodialysis, hospital haemodialysis and peritoneal dialysis

Purpose

To estimate the direct and indirect costs of end-stage renal disease (ESRD) patients in the first and second years of initiating peritoneal dialysis (PD), hospital-based haemodialysis (HD) and nocturnal home HD.

Methods

A cost analysis was performed to estimate the annual costs of PD, hospital-based HD and nocturnal home HD for ESRD patients from both the health service provider’s and societal perspectives. Empirical data on healthcare resource use, patients’ out-of-pocket costs, time spent on transportation and dialysis by ESRD patients and time spent by caregivers were analysed. All costs were expressed in Hong Kong year 2017 dollars.

Results

Analysis was based on 402 ESRD patients on maintenance dialysis (PD: 189; hospital-based HD: 170; and nocturnal home HD: 43). From the perspective of the healthcare provider, hospital-based HD had the highest total annual direct medical costs in the initial year (mean ± SD) (hospital-based HD = $400 057 ± 62 822; PD = $118 467 ± 15 559; nocturnal home HD = $223 358 ± 18 055; P &lt; 0.001) and second year (hospital-based HD = $360 924  ± 63 014; PD = $80 796 ± 15 820; nocturnal home HD = $87 028 ± 9059; P &lt; 0.001). From the societal perspective, hospital-based HD had the highest total annual costs in the initial year (hospital-based HD = $452 151  ± 73 327; PD = $189 191 ± 61 735; nocturnal home HD = $242 038 ± 28 281; P &lt; 0.001) and second year (hospital-based HD = $413 017 ± 73 501; PD = $151 520 ± 60 353; nocturnal home HD = $105 708 ± 23 853; P &lt; 0.001).

Conclusions

This study quantified the economic burden of ESRD patients, and assessed the annual healthcare and societal costs in the initial and second years of PD, hospital-based HD and nocturnal home HD in Hong Kong. From both perspectives, PD is cost-saving relative to hospital-based HD and nocturnal home HD, except that nocturnal home HD has the lowest cost in the second year of treatment from the societal perspective. Results from this cost analysis facilitate economic evaluation in Hong Kong for health services and management targeted at ESRD patients.