Combination of once-weekly haemodialysis with peritoneal dialysis is associated with lower mortality compared with peritoneal dialysis alone: a longitudinal study

Daily change of peritoneal ultrafiltration volume in patients with hybrid dialysis

INTRODUCTION

Hybrid dialysis is widely used in Japan. Although previous reports have shown the beneficial effects of hybrid dialysis, little is known about the daily change in peritoneal ultrafiltration volume in hybrid dialysis.

METHODS

A multicenter, cross-sectional study was conducted in 25 patients with hybrid dialysis. The primary outcome measure was the change in peritoneal ultrafiltration volume between after HD and before HD, according to PD prescription and PD holiday. The secondary outcome measure was the correlation between the difference in ultrafiltration volume and each factor.

RESULTS

The total ultrafiltration volume and the ultrafiltration volume of glucose dialysate after HD increased from 970 ± 408 to 1151 ± 480 (p < 0.01) and from 576 ± 392 to 750 ± 517 (p < 0.01), respectively, compared with before HD. In contrast, the ultrafiltration volume of icodextrin dialysate did not change (from 470 ± 204 to 494 ± 242, p = 0.40). The difference in total ultrafiltration volume was correlated with the difference in glucose dialysate ultrafiltration volume and hybrid duration, but not with the difference in icodextrin dialysate ultrafiltration volume and peritoneal dialysis duration.

CONCLUSION

This study showed that the peritoneal ultrafiltration volume for glucose dialysate increased after HD compared with before HD in patients with hybrid dialysis, whereas that for icodextrin dialysate did not change.

Causal factors of cardiovascular disease in end-stage renal disease with maintenance hemodialysis: a longitudinal and Mendelian randomization study

Background

The risk factors of cardiovascular disease (CVD) in end-stage renal disease (ESRD) with hemodialysis remain not fully understood. In this study, we developed and validated a clinical-longitudinal model for predicting CVD in patients with hemodialysis, and employed Mendelian randomization to evaluate the causal 6study included 468 hemodialysis patients, and biochemical parameters were evaluated every three months. A generalized linear mixed (GLM) predictive model was applied to longitudinal clinical data. Calibration curves and area under the receiver operating characteristic curves (AUCs) were used to evaluate the performance of the model. Kaplan-Meier curves were applied to verify the effect of selected risk factors on the probability of CVD. Genome-wide association study (GWAS) data for CVD (n = 218,792,101,866 cases), end-stage renal disease (ESRD, n = 16,405, 326 cases), diabetes (n = 202,046, 9,889 cases), creatinine (n = 7,810), and uric acid (UA, n = 109,029) were obtained from the large-open GWAS project. The inverse-variance weighted MR was used as the main analysis to estimate the causal associations, and several sensitivity analyses were performed to assess pleiotropy and exclude variants with potential pleiotropic effects.

Results

The AUCs of the GLM model was 0.93 (with accuracy rates of 93.9% and 93.1% for the training set and validation set, sensitivity of 0.95 and 0.94, specificity of 0.87 and 0.86). The final clinical-longitudinal model consisted of 5 risk factors, including age, diabetes, ipth, creatinine, and UA. Furthermore, the predicted CVD response also allowed for significant (p < 0.05) discrimination between the Kaplan-Meier curves of each age, diabetes, ipth, and creatinine subclassification. MR analysis indicated that diabetes had a causal role in risk of CVD (β = 0.088, p < 0.0001) and ESRD (β = 0.26, p = 0.007). In turn, ESRD was found to have a causal role in risk of diabetes (β = 0.027, p = 0.013). Additionally, creatinine exhibited a causal role in the risk of ESRD (β = 4.42, p = 0.01).

Conclusions

The results showed that old age, diabetes, and low level of ipth, creatinine, and UA were important risk factors for CVD in hemodialysis patients, and diabetes played an important bridging role in the link between ESRD and CVD.

Management of Chronic Heart Failure in Dialysis Patients: A Challenging but Rewarding Path

Chronic heart failure (CHF) is a common complication and cause of death in dialysis patients. Although several clinical guidelines and expert consensus on heart failure (HF) in the general population have been issued in China and abroad, due to abnormal renal function or even no residual renal function (RRF) in dialysis patients, the high number of chronic complications, as well as the specificity, variability, and limitations of hemodialysis (HD) and peritoneal dialysis (PD) treatments, there are significant differences between dialysis patients and the general population in terms of the treatment and management of HF. The current studies are not relevant to all dialysis-combined HF populations, and there is an urgent need for high-quality studies on managing HF in dialysis patients to guide and standardize treatment. After reviewing the existing guidelines and literature, we focused on the staging and diagnosis of HF, management of risk factors, pharmacotherapy, and dialysis treatment in patients on dialysis. Based on evidence-based medicine and clinical trial data, this report reflects new perspectives and future trends in the diagnosis and treatment of HF in dialysis patients, which will further enhance the clinicians' understanding of HF in dialysis patients.

Effect of proactive combination therapy with peritoneal dialysis and hemodialysis on technique survival and mortality

PURPOSE

Clinically relevant evidence for the timing of starting combination therapy with peritoneal dialysis and hemodialysis remains scarce. We retrospectively examined whether combination therapy during the induction phase of dialysis prolongs peritoneal dialysis duration.

METHODS

This retrospective study includes 160 patients who underwent combination therapy from 20 dialysis facilities. Four groups were categorized: combination at peritoneal dialysis induction (n = 12, Proactive combination group), and combination following peritoneal dialysis durations of < 2 years (n = 65), 2-5 years (n = 70), or > 5 years (n = 13). Differences in technique survival of dialysis, mortality, and hospitalization due to cardiovascular events in the groups were observed.

RESULTS

The Proactive combination group had the longer mean duration of combination therapy (3.18 years) comparing to that of combination therapy following peritoneal dialysis (1.45 years), but total peritoneal dialysis duration was shorter than in control groups (4.02 years). Of the 160 cases in the entire cohort, there were 8 deaths, 18 ischemic heart disease hospitalizations, and 18 stroke hospitalizations. The Proactive group had lower crude mortality rate (0/12 cases, 0.0%) and crude hospitalization rate for ischemic heart disease (1/11, 8.3%) than the other groups. However, this cohort study did not have enough statistical power to adjust for patients' background, and we were unable to fully examine the differences in such clinical outcomes by the timing of initiation of combination therapy.

CONCLUSION

Use of combination therapy in the induction phase might prolong the duration of combination therapy, but is not necessarily effective for prolonging peritoneal dialysis technique survival.

Advances in Human-Centered Care to Address Contemporary Unmet Needs in Chronic Dialysis

Advances in the treatment of kidney failure with chronic dialysis have stagnated over the past three decades, with over 50% of patients still managed by conventional in-hospital haemodialysis. In parallel, the demands of chronic dialysis medical care have changed and evolved due to a growing population that has higher frailty and multimorbidity. Thus, the gap between the needs of kidney failure patients and the healthcare capability to provide effective overall management has widened. To address this problem, healthcare policy has increasingly aligned towards a human-centred approach. The paradigm shift of human-centred approach places patients at the forefront of decision-making processes, ensuring that specific needs are understood and prioritised. Integration of human-centred approaches with patient care has been shown to improve satisfaction and quality of life. The aim of this narrative is to evaluate the current clinical challenges for managing kidney failure for dialysis providers; summarise current experiences and unmet needs of chronic dialysis patients; and finally emphasise how human-centred care has advanced chronic dialysis care. Specific incremental advances include implementation of renal supportive care; home-assisted dialysis; hybrid dialysis; refinements to dialysis methods; whereas emerging advances include portable and wearable dialysis devices and the potential for the integration of artificial intelligence in clinical practice.

Sustainability of peritoneal dialysis and renal function with proactive combination therapy

Most combined peritoneal dialysis and hemodialysis therapies are used to compensate for the lack of dialysis volume and efficiency in pre-started peritoneal dialysis patients. The aim was to determine the effects on both peritoneal dialysis and residual renal function when proactively combined therapy is started at dialysis induction. This report was based on observation of 10 patients who initiated dialysis therapy with a combination of peritoneal and hemodialysis at induction, and the control group consisted of 24 patients with peritoneal monotherapy in a single dialysis center. The technical survival of peritoneal dialysis therapy and urinary volume and creatinine clearance as residual renal function were assessed. Technical survival of peritoneal dialysis during the 5-year observation period was much better in patients who started with proactive combination therapy than with peritoneal dialysis monotherapy. Between induction and 24 months later, median urinary volume (interquartile value) changed from 1500 (1100-1583) to 800 (545-1875) mL/day and from 1600 (1300-2150) to 1480 (115-1885) mL/day for peritoneal alone and for combination therapy, respectively. Creatinine clearance values changed from 7.0 (6.0-8.7) to 2.0 (1.0-3.0) mL/min for peritoneal alone and from 6.0 (4.0-7.3) to 3.0 (0.5-4.0) mL/min for combination therapy. Though some possible confounding factors, including selection bias, cannot be ruled out, this investigation suggests the benefit of proactive combination dialysis therapy on the sustainability of peritoneal dialysis and residual renal function.

Comparable outcomes between a combination of peritoneal dialysis with once-weekly haemodialysis and thrice-weekly haemodialysis: a prospective cohort study

BACKGROUND

Outcomes of a combination of peritoneal dialysis (PD) and once-weekly haemodialysis (PD + HD) have not been extensively studied.

METHODS

This prospective cohort study using the Japanese Society for Dialysis Therapy Renal Data Registry included those who transitioned from PD to PD + HD therapy or thrice-weekly HD from 2011 to 2018. Exposure was PD + HD therapy compared with thrice-weekly HD. The outcome was time to all-cause or cause-specific death. Associations between PD + HD therapy and outcomes were examined by Cox regression. Sensitivity analyses were performed by propensity score (PS) matching, PS matching with a shared frailty model in which dialysis facilities were treated as a random effect, inverse probability weighting (IPW), PS adjustment, PS stratification, competing risk regression and on-treatment analyses in which data were censored at the transition to thrice-weekly HD for those on PD + HD therapy.

RESULTS

During the study period, 1001 subjects transitioned to PD + HD therapy and 2031 to thrice-weekly HD. During a median follow-up of 3.5 years, 575 subjects died. All-cause, cardiovascular, congestive heart failure-related or infection-related mortality were not significantly different between those on PD + HD and those on thrice-weekly HD [hazard ratio 0.95 (95% confidence interval 0.78-1.16), 1.26 (0.92-1.72), 1.24 (0.77-1.99) and 0.89 (0.57-1.39), respectively]. Sensitivity analyses yielded similar results except that PD + HD therapy was associated with significantly lower all-cause mortality by PS adjustment and PS matching with the shared frailty model and lower infection-related mortality by PS adjustment and IPW.

CONCLUSIONS

PD + HD therapy was associated with similar or potentially lower mortality compared with thrice-weekly HD. Considering a flexible lifestyle, PD + HD therapy could be a great option.

Choice of the Dialysis Modality: Practical Considerations

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

Impact on change in serum beta 2 microglobulin by combination therapy of peritoneal dialysis and hemodialysis: a 12-month preliminary observational study

Background

In the Japanese guidelines on combination peritoneal dialysis (PD) and hemodialysis (HD) therapy, patients with serum beta 2 microglobulin (β2MG) levels less than 30 mg/L are recommended. And PD patients with β2MG more than 30 mg/L are considered to transfer to the PD + HD combination therapy. However, the resultant changes in serum β2MG levels by the introduction of PD + HD combination therapy and the factors influencing the change have not clearly elucidated.

Methods

We retrospectively studied 11 PD patients (mean age 56.4 ± 12.9 years, 10 males) with baseline β2MG levels > 30 mg/L with respect to changes in β2MG and its related factors for 12 months after the introduction of combination therapy of PD plus once a week HD (4 h) using a high-performance dialyzer. Laboratory data including hemoglobin, albumin, C-reactive protein, blood urea nitrogen, creatinine, and the patients’ demographic profiles, and HD-related factors, such as Kt/V and blood flow rate, were assessed.

Results

Serum β2MG levels decreased statistically significantly after the introduction of combination therapy: from 36.7 ± 6.7 mg/L at 0 months, to 33.4 ± 6.1 mg/L at 3 months (p = 0.030, compared to baseline), 32.9 ± 4.5 mg/L at 6 months (p = 0.009), and 33.3 ± 5.3 mg/L at 12 months (p = 0.023), respectively. However, only 27–36% patients achieved target β2MG levels of < 30 mg/L during the observation period. Regarding influencing factors, serum albumin levels, blood flow rates of HD, residual renal function and baseline β2MG were associated with a decrease in serum β2MG levels on univariate analysis. In multivariate analysis, serum albumin at 3 and 12 months correlated significantly with Δβ2MG (β =  − 0.990, p = 0.032 at 3 months, β =  − 0.551, p = 0.033 at 12 months). Urine volume at 12 months correlated significantly with Δβ2MG (β = 0.507, p = 0.019).

Conclusions

Combination therapy of PD and HD might reduce serum β2MG levels, but with marginal efficacy. Our preliminary data indicate that the combination therapy of PD and once weekly HD is not sufficient to significantly decrease serum β2MG levels. Additional HD prescriptions, such as increase in blood flow rate and hemodiafiltration, need to be tested in order to improve β2MG levels in these patients.

Historical overview and current practice of peritoneal dialysis in Japan

In the early days of peritoneal dialysis (PD) therapy, its limited duration and peritoneal deterioration were argued to be its disadvantages. Biocompatible solutions and hybrid therapy have been used in Japan to overcome these issues, which resulted in a decrease in encapsulating peritoneal sclerosis (EPS) incidence and an extension of PD continuation; these results have been disseminated worldwide. Peritoneal dialysis outcomes and practice patterns study (PDOPPS), a prospective observational study, has begun to confirm the outcomes of PD therapy, and sufficient evidence has been published, which has influenced the preparation of PD guidelines. Current thinking about PD emphasizes the need to maintain quality of life and life goals as care goals for patients and to provide high-quality care. However, we must conduct basic research on the prevention of peritoneal deterioration.

Literature review: Combined therapy with peritoneal dialysis and hemodialysis as renal replacement therapy

Background

Peritoneal dialysis (PD) is the recommended renal replacement therapy for patients with end-stage kidney disease. Complementary hemodialysis (HD) once per week for PD patients can aid in achieving adequate dialysis and extend the duration of PD treatment. In Japan, this therapy is termed “combined therapy with PD and hemodialysis (combPDHD).” CombPDHD represents a treatment option for PD patients for whom adequate dialysis cannot be maintained. CombPDHD has been widely applied in Japanese PD patients; however, it is much less common outside of Japan. Clinical evidence, particularly regarding long-term prognosis and appropriate duration of treatment, remains insufficient.

Summary

CombPDHD will be required as an alternative for increasing the dose of PD under various conditions, such as a loss of residual kidney function (RKF) and peritoneal functional failure. The Japanese regimen for combPDHD involves 5 or 6 days of PD, combined with one weekly session of hemodialysis. According to some reports, the potential benefits of combPDHD are peritoneal rest with improved peritoneal function and delay in membrane deterioration. CombPDHD prevents peritoneal dysfunction and reduces cardiovascular complications by adjusting the fluid volume and improving renal anemia. Increased D/PCr indicates a deterioration in peritoneal function and is an independent risk factor for encapsulating peritoneal sclerosis (EPS). It is previously reported that no significant differences in combPDHD duration were observed between EPS and non-EPS groups. Laparoscopic findings involving patients with combPDHD revealed that there was a difference in abdominal wall degeneration depending on the intra-abdominal cavity of each case. Recently, prospective studies on long-term peritoneal function, survival, and hospitalization in combPDHD have been reported. However, reviews evaluating combPDHD long-term outcomes in multicenter and prospective studies are lacking.

Conclusion

It is difficult to continue PD alone with a declining RKF or when self-management is poor. Hence, combPDHD should be started to adjust the fluid volume, with adequate dialysis dose and peritoneal rest. This therapy is useful from a lifestyle viewpoint during the transition period from PD to HD and should not be continued indefinitely.

High body mass index is a risk factor for transition to hemodialysis or hybrid therapy and peritoneal dialysis-related infection in Japanese patients undergoing peritoneal dialysis

PURPOSE

Obesity may negatively impact the clinical outcomes of patients undergoing peritoneal dialysis (PD). However, the impact of obesity on PD-related outcomes remains unclear. We herein examined the association of high body mass index (BMI) with complete hemodialysis (HD) transfer, transition to HD and PD/HD hybrid therapy, peritonitis, catheter exit-site and tunnel infection (ESI/TI), and heart failure-related hospitalization.

METHODS

This retrospective cohort study included 120 patients who underwent PD-catheter insertion between January 2008 and June 2018. BMI ≥ 25 kg/m² at the time of PD-catheter insertion was defined as high BMI, and its association with outcomes was analyzed using the log-rank test and Cox proportional hazards models.

RESULTS

The follow-up duration was 46.2 (23.3-75.3) months. The time until transfer to HD and hybrid therapy was significantly shorter in the high BMI group than that in the low BMI group, whereas the time until HD transfer was not significantly different between the two groups (P < 0.001 and 0.18, respectively). Peritonitis-free and ESI/TI-free survivals were significantly shorter in the high BMI group than those in the low BMI group (P = 0.006 and 0.03, respectively). After adjusting for age, sex, diabetes mellitus, and estimated glomerular filtration rate, high BMI remained a significant risk factor for transferring to HD and hybrid therapy, peritonitis, and ESI/TI (hazard ratio [HR] 2.60, P < 0.001; HR 2.08, P = 0.01; HR 2.64, P = 0.02, respectively).

CONCLUSION

BMI ≥ 25 kg/m² is a risk factor for transition to HD and hybrid therapy, peritonitis, and ESI/TI, but not for complete HD transfer in Japanese patients with PD.

Clinical feasibility of transfer to combined therapy with peritoneal dialysis and hemodialysis for patients on peritoneal dialysis: A prospective multicenter study in Japan

INTRODUCTION

Although combined therapy with peritoneal dialysis (PD) and hemodialysis (HD) is widespread in Japan, its clinical utility has been reported only in retrospective or before-and-after test lacking a control group.

METHODS

We conducted a prospective, multicenter, observational cohort study of 176 incident PD patients and compared patient survival and changes in clinical parameters between patients on different dialysis modalities.

RESULTS

During a median follow-up of 41 months, 47 patients transferred to combined therapy and 35 patients transferred directly to HD. Patients transferred to combined therapy had a significantly better survival than those transferred directly to HD. However, we could not establish this difference in a multivariate analysis because only six patients died among these groups. The decreases in urea nitrogen and serum creatinine were more prominent among patients directly transferred to HD.

CONCLUSION

This is the first report revealing clinical feasibility of transfer to combined therapy for PD patients.

Encapsulating Peritoneal Sclerosis and Mortality Related to Infection in Patients on Combination Once-Weekly Hemodialysis with Peritoneal Dialysis

INTRODUCTION

Previous studies showed that the combination of peritoneal dialysis (PD) and once-weekly hemodialysis is associated with lower all-cause and cardiovascular mortality. This study aimed to compare the incidence of encapsulating peritoneal sclerosis (EPS) and infection-related mortality among those on combination therapy and those on PD alone.

METHODS

This prospective study on the Japanese Renal Data Registry included patients on PD from 2010 to 2014. Subjects were followed up until the end of 2015. Exposure of interest was combination therapy compared with PD alone. Patients who transitioned to combination therapy were matched with those on PD alone by propensity scores. Outcomes were EPS and infection-related mortality. Data were analyzed using Cox regression models.

RESULTS

Among the matched cohort, 608 and 869 patients were on combination therapy and on PD alone, respectively. Dialysate-to-plasma creatinine (D/P Cr) ratio decreased over time among those on combination therapy, while the ratio increased among those on PD alone (p = 0.01 by the mixed-effects model). During a median follow-up of 2.5 years, 33 experienced EPS and 55 died of infection. Combination therapy was associated with lower infection-related mortality (HR [95% CI]: 0.52 [0.28-0.95]) but not with EPS (HR: 1.21 [0.61-2.40]). Lower mortality was not limited to intra-abdominal infection but also observed for pulmonary infection. Sensitivity analyses considering the effects of dialysis facilities yielded similar results.

CONCLUSIONS

Combination therapy was associated with lower infection-related mortality. It was also associated with a decline in the D/P Cr ratio over time but not with lower incidence of EPS during the short observation period.