Risk factors for mortality in patients undergoing peritoneal dialysis: a systematic review and meta-analysis

The relationship between changes in peritoneal membrane solute transfer characteristics and cardiac remodeling in patients with peritoneal dialysis

INTRODUCTION

We aimed to determine the relationship between the dilatation of the heart chambers and the change in peritoneal membrane solute transfer characteristics (PMTC) in long-term peritoneal dialysis (PD) patients.

METHODS

This is a retrospective, single-center study including the follow-up of maintenance PD patients. According to the changes in PMTC from baseline to the last visit, patients were divided into three groups; stable (n = 11), increased (n = 41), and decreased transporters (n = 35).

RESULTS

Left atrium (LA) and Right ventricle (RV) dilatation were more prominent in the PMTC-decreased group compared to PMTC-increased and stable groups (p < 0.001 and p = 0.07, respectively). The Cox regression analysis showed that only decreased PMTC was associated with LA dilatation (HR 2.89 [CI 95%1.54, 5.45] p < 0.01) and RV dilatation (HR 3.01 [CI 95%1.40, 6.21] p < 0.01).

CONCLUSION

PD can be associated with unfavorable dynamic changes in cardiac structure and functions even at the subclinical level.

The relationship of platelet distribution width with all-cause and cardiovascular mortality in peritoneal dialysis patients

BACKGROUND

Cardiovascular disease (CVD) is a major complication in peritoneal dialysis (PD) patients. Previous studies have demonstrated that platelet distribution width (PDW) is associated with cardiovascular events in hemodialysis (HD) patients. In this study, we hypothesized that elevated PDW can predict all-cause and cardiovascular mortality in PD patients.

METHODS

We recruited PD patients for a single-center retrospective cohort study from 1 January 2007, to 30 June 2020. Receiver-operating characteristic (ROC) curves were made to determine the PDW cutoff value for predicting all-cause mortality. The propensity score matching (PSM) method was used to improve the equilibrium between groups. The relation of PDW with all-cause and cardiovascular mortality was analyzed by Cox proportional hazards models. Restricted cubic spline (RCS) models were used to determine whether there was a linear relationship between PDW and all-cause and cardiovascular mortality.

RESULTS

A total of 720 PD patients were screened, and 426 PD patients were enrolled after PSM. After adjusting for confounders, Cox proportional hazards models showed that the PDW value was positively correlated with the risk of all-cause and cardiovascular mortality (HR = 1.162, 95% CI 1.057-1.278, p = 0.002 and HR = 1.200, 95% CI 1.041-1.382, p = 0.012). The adjusted RCS analysis further showed that the relationship of PDW with all-cause and cardiovascular mortality was linear (p for nonlinearly = 0.143 and 0.062).

CONCLUSION

Elevated PDW is independently associated with all-cause and cardiovascular mortality in PD patients.

Risk factors and outcomes in patients who switched from peritoneal dialysis to physician-oriented or patient-oriented kidney replacement therapy

BACKGROUND

We aimed to compare the cardiovascular events and mortality in patients who underwent either physician-oriented or patient-oriented kidney replacement therapy (KRT) conversion due to discontinuation of peritoneal dialysis (PD).

METHODS

Patients with end-stage kidney disease who were receiving PD and required a switch to an alternative KRT were included. They were divided into physician-oriented group or patient-oriented group based on the decision-making process. Logistic regression analysis was used to explore the influencing factors related to KRT conversion in PD patients. The association of physician-oriented or patient-oriented KRT conversion with outcomes after the conversion was assessed by using Cox proportional hazards models.

RESULTS

A total of 257 PD patients were included in the study. The median age at catheterization was 35 years. 69.6% of the participants were male. The median duration of PD was 20 months. 162 participants had patient-oriented KRT conversion, while 95 had physician-oriented KRT conversion. Younger patients, those with higher education levels, higher income, and no diabetes were more likely to have patient-oriented KRT conversion. Over a median follow-up of 39 months, 40 patients experienced cardiovascular events and 16 patients died. Physician-oriented KRT conversion increased nearly 3.8-fold and 4.0-fold risk of cardiovascular events and death, respectively. After adjusting for confounders, physician-oriented KRT conversion remained about a 3-fold risk of cardiovascular events.

CONCLUSION

Compared to patient-oriented KRT conversion, PD patients who underwent physician-oriented conversion had higher risks of cardiovascular events and all-cause mortality. Factors included age at catheterization, education level, annual household income, and history of diabetes mellitus.

γ-Gammaglutamyl transferase predicts all-cause mortality within three-year intervals in patients undergoing peritoneal dialysis

OBJECTIVES

Peritoneal dialysis (PD) serves as a vital renal replacement therapy for patients with end-stage kidney disease (ESKD). γ-Gamma-glutamyl transferase (γ-GGT) is a recognized predictor of oxidative stress and mortality. This study aimed to assess the prognostic significance of γ-GGT in predicting all-cause and cardiovascular mortality among PD patients.

METHODS

A retrospective study was conducted, enrolling 640 PD patients from a single center. The one-year, three-year, and five-year mortality rates for all causes and cardiovascular causes were evaluated. Kaplan-Meier survival analysis and multivariate Cox regression analysis were performed.

RESULTS

Within five years of initiating PD, the observed all-cause mortality rates at one, three, and five years were 11.72%, 16.09%, and 23.44%, while cardiovascular mortality rates were 2.97%, 7.34%, and 11.09%, respectively. Lower γ-GGT levels were associated with decreased all-cause mortality during one-, three-, and five-year follow-ups, along with reduced cardiovascular mortality in the first and third years, as indicated by Kaplan-Meier analysis on median γ-GGT groupings. Multivariate Cox regression analysis showed significantly decreased hazard ratios (HRs) for one- to five-year all-cause mortality and cardiovascular mortality in the lower γ-GGT group compared to higher groups. However, when sex differences were eliminated using separate tertile groupings for males and females, only the one- and three-year all-cause mortality rates demonstrated significantly reduced hazard ratios (HRs) in the lower γ-GGT groups.

CONCLUSION

This retrospective study suggests that γ-GGT levels have prognostic significance in predicting one- and three-year all-cause mortality among PD patients when accounting for sex differences.

Hypokalemia in Peritoneal Dialysis: A Systematic Review and Meta-analysis of Prevalence, Treatment, and Outcomes

Rationale & Objective

Hypokalemia is common and potentially life-threatening in patients undergoing peritoneal dialysis (PD). However, the current literature has produced varying results. This study aimed to evaluate the prevalence and adverse outcomes of hypokalemia and the role of potassium supplementation in patients receiving PD.

Study Design

Systematic review and meta-analysis of randomized controlled trials and observational studies.

Setting & Study Populations

Adults receiving maintenance PD.

Selection Criteria for Studies

Studies that investigated the prevalence and adverse outcomes of hypokalemia and the effect of potassium supplementation.

Data Extraction

Two independent reviewers evaluated studies for eligibility and extracted relevant data.

Analytical Approach

Random effects meta-analysis was conducted to pool hazard ratios (HRs) and 95% CIs for the outcomes of interest. The certainty of findings was rated according to the Grading of Recommendations Assessment, Development and Evaluation criteria.

Results

Of 3,632 reports identified, 24 studies involving 60,313 participants met the inclusion criteria. The prevalence of hypokalemia was 37.9% (95% CI, 27.2%-52.7%), 17.7% (95% CI, 12.0%-25.9%), and 4.4% (95% CI, 1.9%-10.2%) in patients with potassium level <4.0, 3.5, and 3.0 mmol/L, respectively. Hypokalemia, according to the study's definition, was associated with increased risks of all-cause mortality (HR, 1.49; 95% CI, 1.18-1.89), cardiovascular mortality (HR, 1.50; 95% CI, 1.19-1.88), and PD-associated peritonitis (HR, 1.42; 95% CI, 1.17-1.73). These associations were consistent but with low to very low certainty. The effect of correcting hypokalemia with potassium supplementation in patients undergoing PD remains uncertain.

Limitations

Heterogeneity persisted across most of the examined subgroups, and observational studies preclude causation.

Conclusions

Hypokalemia is common and portends poorer survival and a higher risk of peritonitis among patients undergoing PD. Further research into the optimal prevention and treatment strategies for hypokalemia is warranted to improve outcomes.

Registration

Registered at PROSPERO with registration number CRD42022358236.

Association between protein energy wasting and peritoneal membrane transport in peritoneal dialysis

Introduction

Background: fast peritoneal transport (FT) has been associated with peritoneal albumin loss and protein energy wasting (PEW); however, this relationship has not been fully studied. Aim: the aim of this study was to analyze the differences in nutritional parameters between fast-transport peritoneal membrane (FT-PET) and slow-transport peritoneal membrane (ST-PET), and analyze the association between FT-PET and PEW in peritoneal dialysis (PD) patients. Methods: a cross-sectional study of patients on PD. Peritoneal transport characteristics were assessed using the peritoneal equilibration test (PET). Malnutrition inflammation score (MIS) was used for PEW identification. Clinical and biochemical characteristics between patients with and without PEW were assessed. Association between FT-PET status and PEW were evaluated using univariate and multivariate logistic regression. Results: a total of 143 patients were included. FT-PET group showed a higher prevalence of hypoalbuminemia, edema, lower phase angle, lower energy intake, and higher values of MIS score. FT-PET was significantly associated with PEW on univariate (OR: 3.5, 95 % CI: 1.56-7.83, p = 0.002) and multivariate models (OR: 2.6, 95 % CI: 1.02-6.6, p = 0.04). This association was maintained in patients where baseline PET was performed after initiating PD therapy (OR: 6.2, 95 % CI: 1.01-38.6, p = 0.04). Conclusion: FT-PET is associated with PEW evaluated by MIS score. Clinical trials to study nutritional interventions personalized to peritoneal-membrane transport characteristics should be designed.

Serum alkaline phosphatase is a strong predictor of mortality in ESKD patients: analysis of the RISCAVID cohort

BACKGROUND

Mortality in hemodialysis (HD) patients remains unacceptably high compared with that of the general population and despite the continuous improvement of dialysis techniques. This study aimed to assess the role of alkaline phosphatase serum levels on cardiovascular and overall mortality in the RISCAVID study cohort through a long follow-up period, looking for associations with known risk factors for poor outcome.

METHODS

In June 2004, a prospective observational study was started focusing on the cardiovascular risk in hemodialysis patients who lived in the north-west area of Tuscany (RISCAVID, "RISchio CArdiovascolare nei pazienti afferenti all'Area Vasta In Dialisi"). The RISCAVID cohort included 572 prevalent patients on maintenance HD for at least three months. Morbid or fatal events were prospectively recorded at 6-month intervals for a follow up time of 216 months.

RESULTS

In univariable Cox regression analysis, dialysis technique, Geriatric Nutritional Risk Index, peripheral vascular disease, and intact parathyroid hormone and total calcium serum levels were significantly associated with baseline alkaline phosphatase serum levels. Cox multivariable analysis showed that elevated serum alkaline phosphatase levels (the highest quartile), advanced age, dialysis vintage, type of vascular access, Geriatric Nutritional Risk Index, C-reactive protein and calcium serum levels, history of cardiovascular disease and peripheral vascular disease were independent predictors of overall mortality in maintenance HD patients. The fourth quartile of alkaline phosphatase was associated with all-cause 10-year mortality (HR: 1.47; 95% CI: 1.177-1.834) with a 47% increase with respect to the 1st, 2nd, and 3rd quartiles. This was also observed for 18-year all-cause mortality.

CONCLUSIONS

Adjusted proportional analysis showed the alkaline phosphatase value to be an independent and powerful predictor of overall mortality in the hemodialysis population.

Factors associated with stigma in patients undergoing hemodialysis: a meta-analysis and systematic review

BACKGROUND

Patients with hemodialysis (HD) frequently encounter stigma, which impacts their social network and adherence to treatment, increasing their risk of depression and lowering their quality of life. The factors associated with stigma among patients with HD remain poorly understood due to insufficient evidence. To fill this gap, this meta-analysis was conducted.

METHODS

We carried out a thorough literature review in both Chinese and English databases like China National Knowledge Infrastructure (CNKI), Wan Fang Knowledge Data Service Platform, PubMed, Embase, PsycINFO, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and Web of Science. We included literature up to May 25, 2024, focusing on the levels and factors related to stigma in HD patients. Data extraction and quality assessment of the included literature were separately carried out by two researchers, who also independently did the literature screening. Data analysis was carried out using Stata 15.1 software. The possible sources of heterogeneity were explored by sensitivity analysis and subgroup analysis, and the robustness of the results was evaluated.

RESULTS

A total of 12 papers were included, and the quality of these papers was evaluated as moderate or above. The findings of the meta-analysis demonstrated that the pooled stigma mean score was 59.30 [95% (Confidence interval) CI: 55.62 to 62.97]. Per capita monthly family income [MD (Mean Deviation) =4.95, 95% CI (1.55 to 8.35), P=0.004], residence [MD=-4.66, 95% CI (-6.96 to -2.36), P<0.001], complications [MD=4.76, 95% CI (0.92 to 8.61), P=0.015], family function [Z=-0.29, 95% CI (-0.38 to -0.21), P<0.001], self-efficacy [Z=-0.37, 95% CI (-0.48 to -0.26), P<0.001], levels of social support [Z=-0.35, 95% CI (-0.45 to -0.25), P<0.001], and levels of psychological distress [Z=0.59, 95% CI (0.26 to 0.91), P<0.001] were all significant factors contributing to stigma in patients undergoing HD.

CONCLUSION

Healthcare professionals should pay attention to the early assessment of stigma in patients with HD, implement personalized interventions targeting related factors, and promote effective coping strategies for managing the disease.

Inflammation and all-cause mortality in patients undergoing peritoneal dialysis

OBJECTIVE

This study aimed to evaluate inflammatory biomarkers in patients undergoing peritoneal dialysis and investigate their association with all-cause mortality or transfer to hemodialysis.

METHODS

This prospective cohort study included 43 patients undergoing peritoneal dialysis. Plasma levels of cytokines were measured using flow cytometry and capture enzyme-linked immunosorbent assay. Biomarkers were categorized based on their respective median values. Survival analysis was conducted using the Kaplan-Meier estimator, considering two outcomes: all-cause mortality and transfer to hemodialysis.

RESULTS

After adjusting for confounding factors, plasma levels above the median of the levels of CCL2 and plasma, as well as below the median of TNF-α, and the median of dialysate IL-17 levels, were associated with an increased risk of experiencing the specified outcomes after approximately 16 months of follow-up.

CONCLUSION

These findings suggest that inflammatory biomarkers may be a valuable tool for predicting all-cause mortality and transfer to hemodialysis in patients undergoing peritoneal dialysis.

Cognitive Dysfunction Screening in Peritoneal Dialysis Patients: A Cross-Sectional Study

Background

Mild cognitive impairment (MCI) in peritoneal dialysis (PD) patients has been described as a risk factor for worse outcomes such as peritonitis, technique failure, and mortality. In this study, we aimed to determine the prevalence of MCI in a population of PD patients and identify the possible risk factors associated with MCI.

Materials and Methods

We performed an observational, cross-sectional study to evaluate cognitive function using the Montreal Cognitive Assessment (MOCA) test and the Mini Mental State Examination (MMSE) test in PD patients. Patients with diagnosis of dementia or severe neurologic impairment, active cancer, or infection were excluded.

Results

We evaluated 66 patients (mean age 60 years); 53% were male. Prevalence of MCI assessed by MOCA test and MMSE test was 65% and 33%, respectively. Predictors of MCI with MOCA test were higher age (P = 0.0001), lower education level (P = 0.005), need of a helper (P = 0.009), and continuous ambulatory PD modality (P = 0.019). Higher Charlson comorbidity index (P = 0.002), coronary artery disease (P = 0.006), and peripheral artery disease (P = 0.033) were also associated with MCI. Lower Kt/V (P = 0.012) and lower levels of normalized protein catabolic rate (nPCR; P < 0.000) were related to MCI. MCI patients had more episodes of peritonitis (P = 0.047). Multivariable analysis showed that lower education, Kt/V, and nPCR were the most relevant factors connected to MCI (P = 0.029, P = 0.037, and P = 0.019, respectively).

Conclusion

In our PD population, MCI was detected in more than half of the patients. Patients with MCI were older, had lower education level, more disease burden, and higher risk for developing peritonitis. Lower Kt/V and nPCR levels were associated with MCI.

Serum Lipoprotein(a) Levels as a Predictor of Aortic Stiffness in Patients on Long-Term Peritoneal Dialysis

BACKGROUND Lipoprotein (a) [Lp(a)] is associated with atherosclerosis and cardiovascular mortality in patients with kidney failure. Aortic stiffness (AS), measured primarily by carotid-femoral pulse wave velocity (cfPWV), reflects vascular aging and precedes end-organ failure. This study aimed to evaluate the association between serum Lp(a) levels and cfPWV in patients undergoing peritoneal dialysis (PD). MATERIAL AND METHODS In this cross-sectional study, which included 148 patients with long-term PD for end-stage kidney failure, cfPWV was measured using a cuff-based method. AS was defined as a cfPWV exceeding 10 m/s, and an enzyme-linked immunosorbent assay was used to determine serum Lp(a) levels. Univariate and multivariate regression analyses were performed to identify the clinical correlates of AS. RESULTS There were 32 (21.6%) patients diagnosed with AS. Based on the multivariate logistic regression analysis, the odds ratio for AS was 1.007 (95% confidence interval, 1.003-1.011; P=0.001) for every 1 mg/L increase in Lp(a) levels. Multivariate linear regression analysis showed that Lp(a) (P<0.001), age (P=0.003), waist circumference (P=0.008), systolic blood pressure (P=0.010), and diabetes mellitus (P<0.001) were positively associated with cfPWV. The area under the receiver operating characteristic curve for Lp(a) in differentiating AS from non-AS was 0.770 (95% confidence interval, 0.694-0.835; P<0.0001). CONCLUSIONS Serum Lp(a) level was independently associated with cfPWV and AS in patients with PD.

Characteristics of patients and facility of peritoneal dialysis in Korea: Results from the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) Korea

BACKGROUND

Varying peritoneal dialysis (PD)-related clinical outcomes have been reported in different countries. As a participant of the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS), this study investigated the characteristics of Korean PD patients, PD facilities and the incidence rates of clinical outcomes including mortality and PD-related outcomes.

METHODS

From July 2019 to December 2021, a total of 766 Korean PD patients were included for analysis. Poisson regression analysis was used to explore the incidence rates of various clinical events including mortality, modality transfer, exit site or catheter tunnel infection and peritonitis.

RESULTS

Among the 766 patients (median age 55.5 years, males 59.5%), 276 were incident and 490 were prevalent PD patients. The incidence rates of events were as follows: all-cause mortality (0.048), modality transfer (0.051), exit site or catheter tunnel infection (0.054) and peritonitis (0.136) events per person year. The most common causative organism for exit site or tunnel infection was staphylococcus species (47%) and that for peritonitis was streptococcus (28%) followed by staphylococcus (27%) species.

CONCLUSIONS

Up to now, PDOPPS Korea has recruited 766 Korean PD patients and started documentation of major PD-related outcomes which occurred during the follow-up period. The overall incidence rates of clinical outcomes in Korean PD patients were relatively favourable. There was no statistically significant difference in the incidence rates of clinical outcomes according to both facility and patient factors.

Incidence of major cardiovascular events at 1, 2, and 5 years and mortality in incident patients on peritoneal dialysis regarding their nutritional status by bioimpedanciometry: A multicenter study in Colombia

BACKGROUND

The nutritional status of incident patients on peritoneal dialysis (PD) has been associated with survival outcomes. Bioimpedanciometry (BCM) enables to establish a nutritional diagnosis, the volume status, and correlates these findings with survival.

METHODS

This study used a retrospective multicenter historical cohort.

RESULTS

In this study, which included 420 incident patients on peritoneal dialysis with a 5-year follow-up, a cumulative incidence of major adverse cardiovascular events (MACE) of 28.8% was found, being higher in the diabetic population at 36.8%. In regard to the nutritional status in this population, it was found that approximately 44% had altered nutritional status; 34% were found to be in sarcopenia; 6.7% sarcopenic obesity; and 2.8% in obesity (p < 0.001). In the survival analysis, a lower probability of survival was found in patients with overhydration (OH) greater than 3 L (p < 0.001) and in patients with altered nutritional status due to sarcopenia, sarcopenic obesity, and obesity (p 0.016). According to survival in the subgroup of the diabetic population, a lower probability of survival was found in this group of patients (p: 0.011). The overall mortality of the study population was 18%, being higher in the first 2 years, with the most important causes of mortality being cardiovascular. Of the deceased population, 51% were diabetic patients (p: 0.012).

CONCLUSION

In incident patients on peritoneal dialysis, sarcopenic obesity, sarcopenia, overhydration status determined by BCM, and having a diagnosis of diabetes are related to a lower probability of survival; MACE outcomes are more frequent in the diabetic population.

Role of composite objective nutritional indexes in patients with chronic kidney disease

Malnutrition persists as one of the most severe symptoms in patients with chronic kidney disease (CKD) globally. It is a critical risk factor for cardiovascular and all-cause mortality in patients with CKD. Readily available objective indicators are used to calculate composite objective nutritional assessment indexes, including the geriatric nutritional risk index, prognostic nutritional index, and controlling nutritional status score. These indexes offer a straightforward and effective method for evaluating nutritional status and predicting clinical outcomes in patients with CKD. This review presents supporting evidence on the significance of composite nutritional indexes.

Risk factors of different mortality periods in older patients with end-stage renal disease undergoing urgent-start peritoneal dialysis: a retrospective observational study

BACKGROUND

The first six months of therapy represents a high-risk period for peritoneal dialysis (PD) failure. The risk of death in the first six months is higher for older patients treated with urgent-start PD (USPD). However, there are still gaps in research on mortality and risk factors for death in this particular group of patients. We aimed to investigate mortality rates and risk factors for death in older patients with end-stage renal disease (ESRD) receiving USPD within and after six months of therapy.

METHODS

We retrospectively studied the clinical information of older adults aged ≥ 65 years with ESRD who received USPD between 2013 and 2019 in five Chinese hospitals. Patients were followed up to June 30, 2020. The mortality and risk factors for death in the first six months of USPD treatment and beyond were analyzed.

RESULTS

Of the 379 elderly patients in the study, 130 died over the study period. During the follow-up period, the highest number (45, 34.6%) of deaths occurred within the first six months. Cardiovascular disease was the most common cause of death. The baseline New York Heart Association (NYHA) class III-IV cardiac function [hazard ratio (HR) = 2.457, 95% confidence interval (CI): 1.200-5.030, p = 0.014] and higher white blood cell (WBC) count (HR = 1.082, 95% CI: 1.021-1.147, p = 0.008) increased the mortality risk within six months of USPD. The baseline NYHA class III-IV cardiac function (HR = 1.945, 95% CI: 1.149-3.294, p = 0.013), lower WBC count (HR = 0.917, 95% CI: 0.845-0.996, p = 0.040), lower potassium levels (HR = 0.584, 95% CI: 0.429-0.796, p = 0.001), and higher calcium levels (HR = 2.160, 95% CI: 1.025-4.554, p = 0.043) increased the mortality risk after six months of USPD.

CONCLUSION

Different risk factors correlated with mortality in older adults with ESRD within and after six months of undergoing USPD, including baseline NYHA class III-IV cardiac function, WBC count, potassium, and calcium levels.

Vascular calcification inhibitors and cardiovascular events in peritoneal dialysis patients

The prevalence of cardiovascular diseases is high among patients with chronic kidney disease (CKD) and peritoneal dialysis (PD) patients, which increases morbidity and mortality in this population and represents a significant financial burden for both the patients and the healthcare systems. Vascular calcification (VC) is associated with increased morbidity and mortality and VC risk is higher in patients with CKD than in healthy individuals. Calcification inhibitors, compounds that inhibit VC, were discovered as a result of efforts to explain why some patients are spared. It was found that certain proteins (e.g., fetuin-A, osteopontin, osteoprotegerin, bone morphogenetic protein-7) inhibit calcification in dialysis patients. In this narrative review, we provide an overview of known calcification inhibitors, describe the relevant regulatory mechanisms, and discuss their relation to VC development in PD patients.

Association between systemic immune inflammation Index and all-cause mortality in incident peritoneal dialysis-treated CKD patients: a multi-center retrospective cohort study

BACKGROUND

Chronic inflammatory disorders in peritoneal dialysis (PD) contribute to the adverse clinical outcome. Systemic immune inflammation index (SII) is the novel and convenient measurement that is positively associated with various diseases. However, scarce is known regarding the association between SII with all-cause mortality among PD patients.

METHODS

In this multi-center retrospective cohort study, 1,677 incident patients with PD were enrolled. Eligible patients were stratified into groups based on SII level: tertile 1(< 456.76), tertile 2(456.76 to 819.03), and tertile 3(> 819.03). The primary endpoint was the all-cause mortality. Both Cox regression analysis and competing risk models were used to examine the association between SII and all-cause mortality. Subgroup analysis was performed to assess the influence of the SII tertiles on all-cause mortality in different subgroups.

RESULTS

During the follow-up period of 30.5 ± 20.0 months, 26.0% (437/1,677) patients died, of whom the SII tertile 3 group accounted for 39.1% (171/437) of the deaths. Patients in the SII tertile 3 group had a higher all-cause mortality rate than patients in the SII tertile 1 and 2 groups (log-rank = 13.037, P < 0.001). The SII tertile 3 group was significantly associated with 80% greater risk (95% confidence interval:1.13 to 2.85; P = 0.013) compared with the SII tertile 1 group in multivariable Cox regression analysis. The competing risk model also indicated that the relationship between SII tertiles and all-cause mortality remains (subdistribution hazard ratio: 1.86; 95% confidence interval: 1.15 to 2.02, P = 0.011). Furthermore, the relationship between the log-transformed SII and all-cause mortality in patients with PD was nearly linear (P = 0.124).

CONCLUSION

A close relationship was observed between the SII and all-cause mortality in patients undergoing PD, suggesting that more attention should be paid to the SII, which is a convenient and effective measurement in clinical practice.

Machine learning algorithms for the prediction of adverse prognosis in patients undergoing peritoneal dialysis

BACKGROUND

An appropriate prediction model for adverse prognosis before peritoneal dialysis (PD) is lacking. Thus, we retrospectively analysed patients who underwent PD to construct a predictive model for adverse prognoses using machine learning (ML).

METHODS

A retrospective analysis was conducted on 873 patients who underwent PD from August 2007 to December 2020. A total of 824 patients who met the inclusion criteria were included in the analysis. Five commonly used ML algorithms were used for the initial model training. By using the area under the curve (AUC) and accuracy (ACC), we ranked the indicators with the highest impact and displayed them using the values of Shapley additive explanation (SHAP) version 0.41.0. The top 20 indicators were selected to build a compact model that is conducive to clinical application. All model-building steps were implemented in Python 3.8.3.

RESULTS

At the end of follow-up, 353 patients withdrew from PD (converted to haemodialysis or died), and 471 patients continued receiving PD. In the complete model, the categorical boosting classifier (CatBoost) model exhibited the strongest performance (AUC = 0.80, 95% confidence interval [CI] = 0.76-0.83; ACC: 0.78, 95% CI = 0.72-0.83) and was selected for subsequent analysis. We reconstructed a compression model by extracting 20 key features ranked by the SHAP values, and the CatBoost model still showed the strongest performance (AUC = 0.79, ACC = 0.74).

CONCLUSIONS

The CatBoost model, which was built using the intelligent analysis technology of ML, demonstrated the best predictive performance. Therefore, our developed prediction model has potential value in patient screening before PD and hierarchical management after PD.

Neutrophil Percentage-to-Albumin Ratio and Risk of Mortality in Patients on Peritoneal Dialysis

Background

Neutrophil percentage-to-albumin ratio (NPAR), a new inflammatory marker, has been shown to be associated with poor prognosis in patients with cardiovascular disease. However, limited evidence is available for its role in peritoneal dialysis (PD) patients. Our study aimed at investigating the prognostic value of NPAR for mortality in PD patients.

Patients and Methods

This was a single center retrospective cohort study. A total of 1966 PD patients were enrolled in our study from January 2006 to December 2016 and were followed up until December 2021. Patients were stratified into tertiles according to baseline NPAR levels. The associations between NPAR levels with all-cause and cardiovascular mortality were estimated using Cox proportional hazards models. Receiver operating characteristic (ROC) analysis was performed to compare the mortality predictive values of NPAR and other known biomarkers, such as NLR (neutrophil-to-lymphocyte ratio), PLR (platelet-to-lymphocyte ratio), LHR (low-density lipoprotein cholesterol-to-high-density lipoprotein cholesterol ratio) and MLR (monocyte-to-lymphocyte ratio).

Results

During a median follow-up of 48.1 months, 503 (25.6%) patients died, in which cardiovascular disease (CVD) death dominated 50.3%. Multivariate Cox regression analysis revealed that the highest NPAR tertile was significantly associated with a higher risk of all-cause and cardiovascular mortality (HR 1.51, 95% CI 1.14-1.98; HR 1.57, 95% CI 1.07-2.31; respectively) compared with tertile 1. The AUC values of NPAR were 0.62 (95% CI 0.60-0.65, P < 0.001) for all-cause mortality and 0.61 (95% CI 0.57-0.65, P < 0.001) for cardiovascular mortality.

Conclusion

Our study showed that higher NPAR levels were independently associated with increased risk of all-cause and cardiovascular mortality in PD patients. Notably, our results demonstrated that NPAR exhibited superior predictive value for mortality compared to NLR, PLR, MLR, and LHR.

Phase Angle as a Risk Factor for Mortality in Patients Undergoing Peritoneal Dialysis

Phase angle (PhA) is measured using bioimpedance analysis and calculated using body reactance and resistance in the waveform at 50 kHz. Further studies are necessary to clarify the predictive efficacy of PhA in the mortality of peritoneal dialysis (PD) patients. The objective of this study was to assess the utility of PhA for predicting patient mortality and technique failure and compare the predictability of PhA with other risk factors. Our study had a retrospective cohort design. Our center routinely evaluates bioimpedance measurements for all prevalent PD patients (n = 199). The PhA was measured using multifrequency bioimpedance analysis. Our study evaluated patient and technique survival. There were 66, 68, and 65 patients in the low, middle, and high tertiles of PhA, respectively. The PhA values of the low, middle, and high tertiles were 3.6° (3.4-3.9), 4.4° (4.2-4.7), and 5.5° (5.2-6.0), respectively. The 5-year patient survival rates for the high, middle, and low tertiles were 100%, 81.7%, 69.9%, respectively (p < 0.001). The 5 year technique survival rates for the high, middle, and low tertiles were 91.9%, 74.8%, 63.7%, respectively (p = 0.004). Patient and technique survival increased as the PhA tertiles increased. Both univariate and multivariate Cox regression analyses demonstrated a consistent pattern. The prediction of patient or technique survival was better in PhA than in the other classical indicators. The present study demonstrated that PhA may be an effective indicator for predicting patient or technique survival in PD patients. Furthermore, it suggests that routine measurement of PhA and pre-emptive intervention to recover PhA according to causes of low PhA may help improve patient or technique survival in PD patients.

Influencing factors for residual kidney function in incident peritoneal dialysis patients: a systematic review and meta-analysis

BACKGROUND

Residual kidney function (RKF) impacts patients' survival rate and quality of life when undergoing peritoneal dialysis (PD). This meta-analysis was conducted to systematically identify risk and protective factors associated with RKF decline and loss.

METHODS

We searched three English and one Chinese databases from inception to January 31, 2023, for cohort and cross-sectional studies exploring factors associated with RKF decline or loss. The random effects model was employed to aggregate risk estimates and 95% confidence intervals (CIs) from multivariate analysis. Sensitivity and subgroup analyses were performed to explore the heterogeneity among the studies.

RESULTS

Twenty-seven studies comprising 13549 individuals and 14 factors were included in the meta-analysis. Based on the meta-analysis results, risk factors involving male gender (hazard ratio (HR) 1.689, 95%CI 1.385-2.061), greater body mass index (BMI) (odds ratio (OR) 1.081, 95% confidence interval (CI) 1.029-1.135), higher systolic blood pressure (SBP) (HR 1.014, 95%CI 1.005-1.024), diabetes mellitus (DM) (HRRKF loss 1.873, 95%CI 1.475-2.378), DM (ORRKF decline 1.906, 95%CI 1.262-2.879), peritonitis (relative ratio (RR) 2.291, 95%CI 1.633-3.213), proteinuria (OR 1.223, 95%CI 1.117-1.338), and elevated serum phosphorus (RR 2.655, 95%CI 1.679-4.201) significantly contributed to the risk of RKF decline and loss in PD patients. Conversely, older age (HR 0.968, 95%CI 0.956-0.981), higher serum albumin (OR 0.834, 95%CI 0.720-0.966), weekly Kt/V urea (HR 0.414, 95%CI 0.248-0.690), baseline urine volume (UV) (HR 0.791, 95%CI 0.639-0.979), baseline RKF (HR 0.795, 95%CI 0.739-0.857) exhibited protective effects. However, diuretics use, automatic peritoneal dialysis (APD) modality and baseline RKF did not significantly impact RKF decline.

CONCLUSIONS

Patients with male gender, greater BMI, higher SBP, DM, peritonitis, proteinuria, and elevated serum phosphorus might have a higher risk of RKF decline and loss. In contrast, older age, higher serum albumin, weekly Kt/V urea, baseline UV, and baseline RKF might protect against RKF deterioration.

Serum uric acid to creatinine ratio as a risk factor for mortality among patients on continuous ambulatory peritoneal dialysis: a multi-center retrospective study

BACKGROUND

Serum uric acid to serum creatinine ratio (SUA/Scr) has emerged as a new biomarker, which is significantly associated with several metabolic diseases. However, no study has investigated the association between SUA/Scr and mortality among patients on continuous ambulatory peritoneal dialysis (CAPD).

METHODS

In this multicenter retrospective cohort study, we enrolled CAPD patients in eight tertiary hospitals in China from 1 January 2005 to 31 May 2021. Cox proportional hazard models were used to determine the relationship between SUA/Scr and mortality.

RESULTS

A total of 2480 patients were included; the mean age was 48.9 ± 13.9 years and 56.2% were males. During 12648.0 person-years of follow-up, 527 (21.3%) patients died, of which 267 (50.7%) deaths were caused by cardiovascular disease. After multivariable adjustment for covariates, per unit increase in SUA/Scr was associated with a 62.9% (HR, 1.629 (95% confidence interval (CI) 1.420-1.867)) and 73.0% (HR, 1.730 (95% CI 1.467-2.041)) higher risk of all-cause and cardiovascular mortality. Results were similar when categorized individuals by SUA/Scr quartiles. Compared with the lowest quartile of SUA/Scr, the highest and the second highest quartile of SUA/Scr had a 2.361-fold (95% CI 1.810-3.080) and 1.325-fold (95% CI 1.003-1.749) higher risk of all-cause mortality, as well as a 3.701-fold (95% CI 2.496-5.489) and 2.074-fold (95% CI 1.387-3.100) higher risk of cardiovascular mortality. Multivariable-adjusted spline regression models showed nonlinear association of SUA/Scr with mortality in CAPD patients.

CONCLUSIONS

Higher levels of SUA/Scr were associated with higher risk of all-cause and cardiovascular mortality in CAPD patients.

Mortality risk factors among patients undergoing hemodialysis in a nursing home

AIM

This study aimed to verify the impact of low body mass index (BMI) on mortality in nursing home residents undergoing hemodialysis and to clarify other associated mortality risk factors.

METHODS

This retrospective study included patients admitted to a nursing home affiliated with Nagasaki Renal Center between April 2014 and March 2022. Medical data were collected on admission, and participants were divided into low and high BMI groups according to their median BMI values. The patients were followed up until March 2023. The association between survival and patient history was also analyzed.

RESULTS

Of the 106 patients (average age, 81.3 ± 7.9 years; male, 36.8%; median dialysis vintage, 32.5 [interquartile range (IQR), 13.8-79.3] months), 52 and 54 were classified into the low (median < 18.4 kg/m2 ) and high (≥18.4 kg/m2 ) BMI groups, respectively. Multivariable Cox proportional hazards analysis indicated that BMI (hazard ratio, 0.87; 95% confidence interval [CI]: 0.82-0.94; P < 0.001) was closely associated with survival. Multivariable logistic regression revealed that dementia was associated with low BMI (odds ratio: 2.89, 95% CI: 1.07-7.83, P = 0.03).

CONCLUSIONS

Low BMI was an important factor contributing to poor patient survival. Dementia was associated with low BMI. Therefore, the management of both nutrition and dementia is essential for nursing home residents undergoing hemodialysis. Geriatr Gerontol Int 2023; 23: 660-664.

Microbial Profile, Peritoneal Fluid White Blood Cell Count, and Outcome of Peritoneal Dialysis-Related Peritonitis at Indonesian Tertiary Hospital

Introduction

Peritonitis caused by peritoneal dialysis (PD) remains a common complication of continuous ambulatory PD (CAPD). The purpose of this study is to determine the microbial profile in CAPD-related peritonitis, the optimal cutoff of white blood cell (WBC) count, and the percentage of polymorphonuclear (PMN) in CAPD fluid in the prediction of CAPD-related peritonitis, together with the outcome of CAPD-related peritonitis at an Indonesian tertiary hospital. This is a retrospective cohort study of CAPD-related peritonitis patients at Indonesian tertiary hospitals from November 2020 to October 2022.

Methods

Patients with suspected CAPD-related peritonitis who were tested for CAPD fluid culture and WBC count in CAPD fluid were eligible for this study. Patient's diagnosis and outcome obtained from medical records. Differences in clinical outcomes by category of microorganisms were analyzed with Fisher exact test. The Mann-Whitney test and receiver operating characteristic curve were used to determine optimal WBC and PMN cutoff.

Results

This study included 58 patients and 102 episodes of CAPD-related peritonitis. CAPD-related peritonitis was caused by 29.4% Gram-negative bacteria, 21.5% Gram-positive bacteria, 7.8% fungi, and 6.9% polymicrobial bacteria. CAPD fluid WBC count >79 cells/μL and PMN percentage >50% had a sensitivity of 76.4% and a specificity of 92.9% in predicting CAPD-related peritonitis. There was a significant difference in outcome between Gram-negative and Gram-positive bacterial peritonitis.

Conclusions

It is critical to understand the microbial profile in CAPD-related peritonitis. Lower WBC count cutoff points in CAPD fluids may improve sensitivity in predicting CAPD-related peritonitis.

Serum platelet distribution width predicts cardiovascular and all-cause mortality in patients undergoing peritoneal dialysis

BACKGROUND

Platelet distribution width (PDW) is a predictor for all-cause mortality in patients with cardiovascular diseases (CVD). This study aimed to evaluate the prognostic implication of PDW in predicting cardiovascular and all-cause mortality in patients undergoing peritoneal dialysis (PD).

METHODS

In total, 762 PD patients from a single center were recruited retrospectively from 2005 to 2017 and followed up until 2021. The primary and secondary outcomes were cardiovascular and all-cause mortality, respectively. Survival analysis was conducted using Kaplan-Meier estimates and Cox regression analysis.

RESULTS

During a median of 52.2 months of follow-up, 135 (17.7%) cases of CVD and 253 (33.2%) cases of all-cause mortality were reported. After multivariate adjustment, high levels of PDW were associated with an increased risk of death from CVD (HR: 1.583; 95% CI: 1.109-2.258; P = 0.011) and all-cause mortality (HR: 1.313; 95% CI: 1.006-1.758; P = 0.045). Subgroup analysis indicated a stronger association between PDW and all-cause mortality among female participants (P-value for interaction = 0.033). Higher levels of PDW predicted an increased risk of all-cause mortality in female patients (HR: 1.986; 95% CI,1.261-3.127).

CONCLUSION

High levels of PDW are independently associated with cardiovascular and all-cause mortality in the PD population, and differences by sex exist in the association of PDW with all-cause mortality.

Hypomagnesemia as a Risk Factor and Accelerator for Vascular Aging in Diabetes Mellitus and Chronic Kidney Disease

The age-old axiom that one is as old as his or her vessels are, calls for ongoing critical re-examination of modifiable risk factors of accelerated vascular ageing in chronic kidney diseases. Attempts to modulate vascular risk with cholesterol-lowering agents have largely failed in advanced chronic kidney disease (CKD). In addition to nitrogen waste products, many pathological biochemical processes also play a role in vascular calcification in chronic kidney damage. Magnesium, a cation vital for the body, may substantially reduce cardiovascular diseases' risk and progression. This narrative review aimed to address the relationship between hypomagnesemia and vascular calcification, which promotes further cardiovascular complications in diabetes, aging, and CKD. Articles with predefined keywords were searched for in the PubMed and Google Scholar databases with specific inclusion and exclusion criteria. We hypothesized that a decrease in serum magnesium levels contributes to increased vascular calcification and thereby increases cardiovascular mortality. In summary, based on existing evidence in the literature, it appears that simple and inexpensive oral magnesium supplementation may reduce the cardiovascular mortality of patients who are already severely affected by such diseases; in this context, the concept of 'normal' vs. 'ideal' serum magnesium levels should be carefully re-examined.

Caractéristiques et mortalité des patients avec et sans syndrome cardio-rénal traités par dialyse péritonéale en France

IntroductionGlobalement, la dialyse péritonéale (DP) est de plus en plus indiquée dans l’insuffisance cardiaque réfractaire. Cette étude a pour but d’analyser les caractéristiques et la survie des patients traités par DP, en les divisant en deux groupes, avec et sans syndrome cardio-rénal (CRS). MéthodesIl s’agit d’une étude rétrospective incluant tous les patients inscrits dans le Registre de Dialyse Péritonéale de Langue Française (RDPLF) entre le 01/01/2010 et le 01/12/2021. La cohorte a été divisée en deux groupes afin de comparer les patients avec et sans CRS. La survie a été analysée par la méthode de Kaplan Meier et une régression de Cox a identifié les facteurs associés avec la mortalité dans les deux groupes. Résultats11730 patients en DP ont été inclus. L’âge moyen était de 66.78±16.72 ans. 766 patient (6,53 %) ont été pris en charge en DP pour CRS et 10 964 pour une autre néphropathie. Les malades avec CRS étaient plus âgés et comorbides. La survie est significativement meilleure dans le groupe sans CRS (Log Rank test < 0.001). La médiane de survie est de 17.7±1.2 mois et 49.6±0.7 mois chez les patients avec et sans CRS respectivement. En analyse multivariée, l’âge, le sexe masculin, le diabète, les pathologies cardio-vasculaires et le manque d’autonomie sont liés à une mortalité accrue dans le groupe sans CRS. Par contre, chez les patients avec CRS, seules les variables âge et antécédent d’hépatopathie sont significativement associées à un sur risque de décès. Le nombre de péritonites présentées par le patient est significativement associé à un moindre risque de décès dans les deux groupes. ConclusionCette étude nationale portant sur un grand nombre de patients traités par DP a révélé les grandes différences dans les caractéristiques et la survie entre ceux qui ont un CRS contre ceux qui n’en ont pas. En particulier, les deux facteurs les plus liés à la mortalité dans le groupe avec CRS sont l’âge et la pathologie hépatique.

A retrospective study of baseline peritoneal transport character and left ventricular hypertrophy in incident peritoneal dialysis patients: interrelationship and prognostic impacts

BACKGROUND

Left ventricular hypertrophy is associated with adverse outcomes among peritoneal dialysis patients. The aim of this study was to evaluate the prognostic impact of baseline left ventricular hypertrophy and its relationship with baseline peritoneal transfer characteristics in peritoneal dialysis patients.

METHODS

We enrolled 151 incident peritoneal dialysis patients to perform a multicentric retrospective cohort study since January 1, 2017 to January 31, 2021. Patients were grouped based on baseline dialysate-to-plasma creatinine ratio at 4 h as follows: low (<0.50), low average (0.5-0.64), high average (0.65-0.80) and high (≥0.81). Echocardiography and clinic data were recorded yearly. The Cox proportional hazards models and competing risk model were used to evaluate patients' survival. Generalized linear mixed models were performed to explore risk factors associated with left ventricular hypertrophy.

RESULTS

During a median follow-up period of 33 months (range, 16-48 months), 21 (13.9%) patients died, including 16 (10.60%) cardiovascular deaths. Controlling the competing risks of switching to hemodialysis, kidney transplantation and loss to follow-up, baseline left ventricular hypertrophy was an independent risk factor for all-cause mortality (subdistribution hazard ratio, 2.645; 95% confidence interval, 1.156-6.056; p = 0.021). Baseline high and high average transport status were positively related to left ventricular mass index and left atrium diameter 2 years after PD initiation.

CONCLUSION

Baseline fast peritoneal solute transport rate may be an effect factor for aggravating left ventricular hypertrophy which predicted poor outcomes for peritoneal dialysis patients. The findings offered important ideas for further prospective intervention study.

Dialysis Duration and Glucose Exposure Amount Do Not Increase Mortality Risk in Peritoneal Dialysis Patients: A Population-Based Cohort Study From 2004 to 2012

Background

Although the bio-incompatibility of glucose-based peritoneal dialysis (PD) solution is well documented, it is used worldwide. How PD duration and the amount of dialyzate glucose exposure affect survival in patients with end-stage renal disease remain inconclusive due to improper study designs in the extant literature.

Methods

All incident patients with PD from 2004 to 2007 who were older than 18 years in Taiwan were included. Patients were censored when they received a transplant or at the end of 2012. Glucose exposure through PD solution was calculated by the mean glucose contained per liter when receiving PD. For those who had already shifted to hemodialysis (HD) and survived longer than 2, 3, and 4 years (the index dates), the cause-specific Cox regression model was used to make the survival comparison by PD duration and mean glucose concentration in these three cohorts, respectively. The model was adjusted by demographics, case-mix, time cohort (2004–2005 vs. 2006–2007), peritonitis episode (none vs. ≥once), and mean PD solution glucose exposure (tertile).

Results

A total of 3,226 patients were included, with a mean age of 53.4 ± 15.2 years, 44.6% being male, and 34.2% having diabetes mellitus. The 1, 2, 3, and 4-year survival rates were 94, 87, 80, and 74%, while technical survival rates were 86, 70, 56, and 45%, respectively. The overall transplant events were 309 (9.6%) only. There were 389, 495, and 553 incident patients with PD shifting to HD included in 2-, 3-, and 4-year cohort, respectively. The population with moderate glucose concentration exposure had the highest mortality, and the high glucose concentration exposure had non-significant lower mortality in each cohort. In various fixed time-window cohorts, the duration of PD treatment did not increase mortality risk after adjustments. In addition, glucose exposure did not affect the mortality rate.

Conclusion

For incident PD patients with PD duration no longer than 4 years, neither PD duration nor glucose exposure amount increases the long-term mortality risk.

Iron Deficiency is Associated With Platelet Count Elevation in Patients With Dialysis-dependent Chronic Kidney Disease

OBJECTIVE

Iron deficiency is common in patients with end-stage renal disease (ESRD). Platelet count changes may reflect iron status, but the relationship between platelet count and iron indices is unclear in patients with ESRD.

METHODS

We conducted a retrospective study in 1,167 patients with ESRD from 2012 to 2017 in West China Hospital. Baseline data were used to analyze the relationship between the platelet count and iron indices. Patients were followed up for 3 years.

RESULTS

Patients with iron deficiency (both absolute and functional) had a higher platelet count than those without iron deficiency (174 ± 61 × 10⁹/L vs. 153 ± 58 × 10⁹/L, P < .001). Receiver operating characteristic analysis showed a weak predictive power of platelet count on absolute iron deficiency (area under curve 0.620; cutoff value > 137 × 10⁹/L, sensitivity 76%, specificity 43%) and functional iron deficiency (area under curve 0.540; cutoff value > 124 × 10⁹/L, sensitivity 77%, specificity 32%). Platelet count was negatively correlated with ferritin (Spearman's rho [ρ] -0.1547, P < .001), transferrin saturation (ρ = -0.1895, P < .001), and serum iron (ρ = -0.1466, P < .001). The abovementioned correlations remained significant in multivariate regression (β -0.7285, 95% confidence interval [CI] -1.0757 to -0.3814; β -.00347, 95% CI -0.0520 to -0.0174; β -0.0097, 95% CI -0.0159 to -0.0035, respectively). In unadjusted and adjusted Cox regression models, neither baseline platelet count nor relative thrombocytosis was associated with 3-year mortality.

CONCLUSION

There was a weak but significant platelet count elevation in patients with ESRD and with iron deficiency.

KEY WORDS

end-stage renal disease; iron deficiency; iron supplement; mortality; platelet count.