Chronic peritoneal dialysis in octogenarians

Peritoneal dialysis-related infections in elderly patients

This review outlines the epidemiology, characteristics, risk factors, and prognosis of peritoneal dialysis (PD)-related peritonitis, PD catheter-related infections, and the effects of assisted PD in elderly patients from the Japanese perspective. Based on the literature, the incidence of peritonitis is likely to be higher in elderly patients than in younger patients. The most frequent causative bacteria in elderly patients are Gram-positive bacteria, as in adult PD patients, most commonly due to transcatheter infection. However, elderly patients may have difficulty recognizing cloudy drainage fluid due to decreased visual acuity. Hypokalemia, the use of gastric acid suppressants, prophylactic antibiotic use before endoscopy, biocompatible fluids and hypoalbuminemia considered modifiable risk factors for peritonitis. However, the mechanism by which treatment of hypokalemia prevents peritonitis is unknown. Currently, the relationship between gastric acid suppression therapy and peritonitis in elderly patients is debatable, with no evidence to strongly recommend uniform discontinuation of gastric acid suppression therapy. Exit-site infection (ESI) is a major risk factor for the development of peritonitis, and appropriate prevention and management of ESI may reduce infection-related hospitalizations in PD patients. Currently, no randomized, controlled trials have verified the effectiveness of antibiotic application for ESI in Japan, but results from other countries are awaited. In assisted PD, it is extremely important that family members, caregivers, and nurses who support the procedure receive sufficient education and training from medical professionals familiar with PD. Early detection and treatment of PD-related infections are required because the risk of death increases in elderly patients.

Low Serum Albumin Is Associated with Poor Prognosis in Patients Receiving Peritoneal Dialysis Treatment

Background

The number of patients receiving dialysis treatment is sustainably increasing, especially peritoneal dialysis.

Objectives

It is necessary to find out potential factors that may indicate the prognosis of patients receiving peritoneal dialysis treatment.

Methods

This study retrospectively involved 325 patients who received peritoneal dialysis treatment.

Results

Low serum albumin (HR = 2.254; 95% CI: 1.534-3.311; P < 0.001) and high FBG (Fasting blood glucose) (HR = 1.474; 95% CI: 1.025-2.120; P=0.037) were risk factors for death in patients receiving peritoneal dialysis treatment. Serum albumin (AUC = 0.683; P < 0.001) and creatinine (AUC = 0.625; P < 0.001) exhibited value of prognosis prediction. Both high FBG (P=0.005) and low albumin (P < 0.001) were associated with poor prognosis, and low albumin predicted poorer survival.

Conclusions

Low serum albumin and high fasting blood glucose were risk factors and associated with poor prognosis. Low albumin has a potential in predicting the prognosis of patients receiving peritoneal dialysis treatment.

Risk factors for early death in urgent-start peritoneal dialysis patients: A multicenter retrospective cohort study

BACKGROUND

Assess risk factors for early death in patients who underwent urgent-start peritoneal dialysis (USPD).

METHODS

Patients who initiated USPD in five peritoneal dialysis centers from 2013 to 2019 were screened in this multicenter retrospective cohort study. Risk factors for all-cause mortality within 3 months were explored.

RESULTS

A total of 1265 USPD patients with 43 early deaths were included. Cox regression analyses showed that age older than 60 years (hazard ratio [HR], 3.054; 95% CI [1.597, 5.842]; p = 0.001), albumin less than 30 g/L (HR, 2.234; 95%CI [1.207, 4.136]; p = 0.011), blood glucose greater than 7 mmol/L (HR, 2.766; 95%CI [1.477, 5.180]; p = 0.001), higher estimated glomerular filtration rate (eGFR; HR, 1.121; 95%CI [1.071, 1.172]; p = 0.000), and poor stages of heart failure (class IV compared with class 0-I; HR, 5.165; 95%CI [2.544, 10.486]; p = 0.000) were independent predicting factors for early death.

CONCLUSIONS

Risk factors for early death were older age, hypoproteinemia, hyperglycemia, higher eGFR, and severe heart failure.

Improving Outcome in Geriatric Peritoneal Dialysis Patients

Objective

Few data are available about elderly patients on peritoneal dialysis (PD). In the present study, we reviewed our experience with patients aged 70 years or more at the start of peritoneal dialysis (PD).

Design

This retrospective study was conducted at a single center in Japan.

Patients and Methods

Of 222 patients managed using PD at our hospital between 1991 and 2001 (including 219 cases of PD first), 150 patients were aged under 70 years and 72 patients were 70 years of age or older. For the two groups of patients, we determined clinical data, erythropoietin and PD prescriptions, reasons for selecting PD (elderly patients only), urine and ultrafiltration volumes, comprehensive functional assessment, quality of life (QOL), comorbidity, technique survival rate, and causes of death.

Results

Serum creatinine, serum β2-microglobulin, total dose of erythropoietin (EPO) needed to maintain hematocrit at 30%, number of continuous ambulatory peritoneal dialysis (CAPD) exchanges, and total volume of dialysis solution prescribed were significantly lower in the elderly patients as compared with patients aged under 70 years. The main reasons for starting PD in elderly patients at our hospital were advanced age (57%), patient's choice (25%), and cardiovascular complications (9%). Residual renal function was well maintained in CAPD patients aged 70 years or more as compared with patients aged under 70 years. Ultrafiltration volume was lower in the elderly CAPD patients. Scores on the Revised Hasegawa Dementia Scale, the Physical Self-Maintenance Scale, and the Instrumental Activities of Daily Living scale were significantly higher in CAPD patients than in hemodialysis patients. Subjective assessment using a linear analog scale showed a high QOL score in the elderly patients for overall feelings of well-being, mood, and anxiety. At the time of dialysis introduction, the major existing disorders in patients over 80 years of age were mostly cardiovascular disorders such as heart failure, myocardial infarction, serious arrhythmia, and cerebrovascular disease. The median technique survival in patients aged 70 years or more was 31.5 months. The main causes of death in elderly PD patients were heart failure (35.7%), peritonitis (14.3%), and cerebrovascular disease (11.9%).

Conclusion

Peritoneal dialysis should be considered the treatment method of choice when introducing dialysis in elderly patients.

In-Center Intermittent Peritoneal Dialysis: Retrospective Ten-Year Single-Center Experience with Thirty Consecutive Patients

Background

In-center intermittent peritoneal dialysis (IPD) is sometimes performed in elderly and multimorbid patients that have failed hemodialysis and that are unable to perform peritoneal dialysis (PD) at home. Complications, frequency of hospital admission, and survival are often claimed to be dismal although current data are lacking.

Methods

We performed a retrospective cohort study of patients that underwent IPD at Hannover Medical School, Germany, between 1997 and 2007. Underlying renal disorders, comorbidity, and circumstances that precluded hemodialysis and home PD were recorded. Survival, cause of death, episodes of hospitalization, and episodes of peritonitis were calculated. Laboratory values at baseline and after 3 months of IPD were also retrieved.

Results

We identified 30 patients with severe comorbidity (median Charlson Comorbidity Index of 6; n = 30) who underwent IPD for 439 months in total. The majority of patients had vascular/hypertensive nephropathy ( n = 12; 40%); congestive heart failure was the leading cause for choosing PD ( n = 13; 43.3%); 73.3% of our patients had either no partner or at least one disease that precluded home therapy. Hospitalization rate was 1.39 admissions per patient-year and there was 1 episode of peritonitis per 48.8 IPD-months. Mean survival was 26.6 months (median 17 months; n = 30); sepsis was the leading cause of death ( n = 13; 59.1%).

Conclusions

IPD is associated with fewer episodes of peritonitis, fewer admissions, and longer survival than is often believed. Suitable patients in whom palliative care alone seems inappropriate should not be denied a trial of IPD if they so choose.

Variability in Case Mix and Peritoneal Dialysis Selection in Fifty-Nine French Districts

In France, the use of peritoneal dialysis (PD) as the first-choice treatment varies greatly between districts, as it is already known to do between countries. Baseline clinical factors associated with choice of first modality were analyzed in 10815 new end-stage renal disease patients in 59 districts. To describe practices at the district level, we used an agglomerative hierarchical classification, with proximity defined by a likelihood-ratio test that compared multivariate logistic regressions of the following factors: age, gender, diabetes, congestive heart failure, severe behavioral disorders, mobility, and employment. To propose a typology, each cluster of districts was described by a multivariate logistic regression. While populations starting PD in France, as elsewhere, are more likely to be young or employed, they are also more likely to be elderly or have congestive heart failure or severe behavioral disorders. Overall, 14% of patients start with PD, but this rate varies significantly across districts, from 0% to 45%. A specific combination of factors was associated with the first-choice modality in each group of districts. This study highlights the lack of consensual medical criteria for this choice and the likelihood that nonmedical factors may explain the observed differences. The high variability suggests that PD can be used in almost all clinical conditions. Accordingly, patient preference should play a more important role in the decision-making process.

Experiences of Living with Assisted Peritoneal Dialysis - A Qualitative Study

BACKGROUND

People's experiences of living with assisted peritoneal dialysis (aPD) have not been studied previously. Assisted PD is successfully used as renal replacement therapy for elderly and disabled patients with end-stage renal disease. To be treated with aPD implies being dependent on lifelong treatment at home. The aim of this study was to explore adults' experiences of living with aPD.

METHODS

In-depth interviews were conducted with 10 participants with aPD, median age 82.5 years. The text was analyzed using a phenomenological-hermeneutical method.

RESULTS

The participants experienced limitations and an uncertain future, but through different strategies and participation in healthcare, they could still enjoy what was important in life for them. The analysis of the text resulted in 4 main themes; 1) Facing new demands, 2) Managing daily life, 3) Partnership in care, and 4) Experiencing a meaningful life, leading to the comprehensive understanding: 'Striving for maintaining wellbeing'.

CONCLUSION

The participants expressed that they experienced a good quality of life despite being physically frail, severely ill, and in need of home-based lifesaving treatment. The findings suggest that aPD should be available everywhere where PD is offered. Integrating the model of person-centered care may greatly improve the care for persons living with aPD.

Quality of Life, Perceptions, and Health Satisfaction of Older Adults with End-Stage Renal Disease: A Systematic Review

OBJECTIVES

To explore the quality of life (QOL), perceptions, and health satisfaction of older adults with end-stage renal disease (ESRD) undergoing renal replacement therapy (RRT).

DESIGN

Systematic review of literature.

PARTICIPANTS

Individuals with ESRD undergoing RRT aged 65 and older.

MEASUREMENTS

Articles identified from PubMed database search from January 1994 to December 2014. The methodological quality of each of the selected articles was assessed using eight standards adapted from well-established research quality review criteria.

RESULTS

Of the initial 1,401 articles identified, 23 met the inclusion criteria. The age range of study participants examined was 65 to 90. Seventy-eight percent of the studies met six or more of the methodological standards; 47% found overall health-related and mental component summary QOL scores in elderly adults with ESRD to be similar to or higher than those of age-matched controls or younger individuals, although the physical component summary QOL scores tended to be lower in older adults. Only six studies addressed health satisfaction and perceptions of elderly adults with ESRD, with widely variable findings.

CONCLUSION

Few studies specifically examine QOL in elderly adults with ESRD undergoing RRT and even fewer address issues of perceptions and health satisfaction. However, the limited data from the QOL studies looks promising with a significant proportion showing similar or higher overall health-related and mental component summary QOL scores in elderly adults with ESRD. The very limited data on perceptions and health satisfaction of elderly adults with ESRD undergoing RRT makes it difficult to make any generalizable conclusions. Overall, more research is needed to examine these factors in elderly adults with ESRD.

Peritoneal Dialysis-Related Infection in the Older Population

With appropriate training and adequate support, it is possible to keep the peritonitis rate of elderly peritoneal dialysis (PD) patients at a highly respectable level. In general, the latest recommendations for the treatment and prevention of PD-related infections by the International Society for Peritoneal Dialysis (ISPD) are applicable to older patients. However, there are minor differences in the spectrum of causative organisms amongst elderly patients, with coagulase-negative staphylococcal species (CNSS) and Enterobacteriaceae species being more common in elderly patients. Elderly PD patients who develop peritonitis have an excessive short-term mortality, and, amongst elderly patients, a high burden of comorbid load increases the risk of relapsing episodes. In addition, technical problems, social difficulties, and concomitant comorbid diseases often have profound effects on the risk of peritonitis as well as its management.

APPETITE PREDICTS INTAKE AND NUTRITIONAL STATUS IN PATIENTS RECEIVING PERITONEAL DIALYSIS

BACKGROUND

Sub-optimal nutrition status is common amongst patients receiving peritoneal dialysis (PD) and leads to poor clinical outcome. This population experiences multi-factorial challenges to achieving optimal nutritional status, particularly driven by inadequate intake.

OBJECTIVES

The aim of this investigation was to identify factors associated with inadequate protein intake and sub-optimal nutritional status in patients undergoing PD.

DESIGN/PARTICIPANTS

This was a cross-sectional study of 67 adult patients receiving PD (mean age 59 ± 14 years; 57% male) within a single centre. Participants were consecutively recruited and interviewed by renal dietitians, collecting: Subjective Global Assessment (SGA); quality of life (using EQ-5D); dietary intake (via dietary interview); and appetite (using Appetite and Diet Assessment Tool). Participant demographics were obtained via survey or medical charts. Main outcome measures were inadequate dietary protein intake (<1.1 g/kg adjusted body weight/day) and malnutrition (as defined by SGA rating B or C).

RESULTS

Overall, 15 (22%) patients were malnourished and 29 (43%) had inadequate protein intake. Poor appetite (anorexia) was reported in 62% (18/29) of participants with inadequate protein malnourished patients reported anorexia versus 12 (23%) of the well-nourished patients (p = 0.0001).

CONCLUSION

Anorexia was a key risk factor for inadequate protein intake and malnutrition in patients undergoing PD. These findings highlight a need to closely monitor patients with appetite disturbances.

Clinical outcomes and mortality in elderly peritoneal dialysis patients

OBJECTIVES

To evaluate the clinical outcomes and identify the predictors of mortality in elderly patients undergoing peritoneal dialysis.

METHODS

We conducted a retrospective study including all incident peritoneal dialysis cases in patients ≥65 years of age treated from 2001 to 2014. Demographic and clinical data on the initiation of peritoneal dialysis and the clinical events during the study period were collected. Infectious complications were recorded. Overall and technique survival rates were analyzed.

RESULTS

Fifty-eight patients who began peritoneal dialysis during the study period were considered for analysis, and 50 of these patients were included in the final analysis. Peritoneal dialysis exchanges were performed by another person for 65% of the patients, whereas 79.9% of patients preferred to perform the peritoneal dialysis themselves. Peritonitis and catheter exit site/tunnel infection incidences were 20.4±16.3 and 24.6±17.4 patient-months, respectively. During the follow-up period, 40 patients were withdrawn from peritoneal dialysis. Causes of death included peritonitis and/or sepsis (50%) and cardiovascular events (30%). The mean patient survival time was 38.9±4.3 months, and the survival rates were 78.8%, 66.8%, 50.9% and 19.5% at 1, 2, 3 and 4 years after peritoneal dialysis initiation, respectively. Advanced age, the presence of additional diseases, increased episodes of peritonitis, the use of continuous ambulatory peritoneal dialysis, and low albumin levels and daily urine volumes (<100 ml) at the initiation of peritoneal dialysis were predictors of mortality. The mean technique survival duration was 61.7±5.2 months. The technique survival rates were 97.9%, 90.6%, 81.5% and 71% at 1, 2, 3 and 4 years, respectively. None of the factors analyzed were predictors of technique survival.

CONCLUSIONS

Mortality was higher in elderly patients. Factors affecting mortality in elderly patients included advanced age, the presence of comorbid diseases, increased episodes of peritonitis, use of continuous ambulatory peritoneal dialysis, and low albumin levels and daily urine volumes (<100 ml) at the initiation of peritoneal dialysis.

Clinical outcomes in elderly patients on chronic peritoneal dialysis: a retrospective study from a single center in china

OBJECTIVES

We aimed to evaluate clinical outcomes and identify the predictors of mortality in elderly patients undergoing continuous ambulatory peritoneal dialysis (CAPD).

METHODS

This retrospective cohort study included all incident CAPD patients treated at our center from 2006 to 2009. Demographic and clinical data on initiation of CAPD and clinical events during the study period were collected. Survival probabilities were generated using the Kaplan-Meier method, and risk factors for mortality were evaluated using Cox proportional hazards models.

RESULTS

Of 805 patients on CAPD, the elderly group (≥65 years; mean age: 71.3 ± 4.3 years) consisted of 148 patients, and the younger group (<65 years; mean age: 43.1 ± 12.2years) consisted of 657 patients. The 1-, 2-, 3-, and 5-year patient survival rates were 97%, 92%, 88%, and 73% for the younger group, and 79%, 67%, 56%, and 30% for elderly group. The patient survival rates were significantly lower for the elderly group than for the younger group (p = 0.000). However, technique survival did not significantly differ between the groups (p = 0.559). In the patients overall, the independent predictors of death were old age (p = 0.003), diabetes (p = 0.000), cardiovascular disease (p = 0.006), lower hemoglobin (p = 0.010), and lower serum albumin (p = 0.024). Mortality in the elderly patients was associated with advanced age [relative risk (RR): 1.088; 95% confidence interval (CI): 1.027 to 1.153; p = 0.004], diabetes (RR: 2.064; 95% CI: 1.236 to 3.445; p = 0.006), and lower serum albumin (RR: 0.940; 95% CI: 0.897 to 0.985; p = 0.010).

CONCLUSIONS

The elderly patients on CAPD experienced technique survival comparable with that of younger patients, but their patient survival was lower. In elderly patients, mortality was determined predominantly by greater age, diabetes, and lower serum albumin. Our results indicate that chronic peritoneal dialysis is a viable dialysis option for elderly patients with end-stage renal disease. Better management of hypoalbuminemia and comorbid conditions might improve survival in elderly PD patients.

A Brazilian experience in assisted automated peritoneal dialysis: a reliable and effective home care approach

INTRODUCTION

Automated assisted peritoneal dialysis (AAPD) has been shown to be successful as renal replacement therapy for elderly and physically incapable end-stage renal disease (ESRD) patients. In early 2003, a pioneer AAPD program was initiated at GAMEN Renal Clinic in Rio de Janeiro, Brazil. ♢

OBJECTIVE

We evaluated the results of an AAPD program offered as an option to elderly ESRD patients with physical or cognitive debilities or as last resort to patients with vascular access failure or hemodynamic instability during hemodialysis. ♢

METHODS

A cohort of 30 consecutive patients started AAPD from January 2003 to March 2008 and was followed to July 2009. Demographics, clinical and laboratory parameters, causes of death, and patient and technique survival were analyzed. ♢

RESULTS

Median age of the patients was 72 years (range: 47 - 93 years), with 60% being older than 65. The Davies score was greater than 2 in 73% of patients, and the Karnofsky index was less than 70 in 40%. The overall peritonitis rate was 1 episode in 37 patient-months. The total duration of AAPD ranged from 3 to 72 months. Patient survival was 80% at 12 months, 60% at 24 months, and 23.3% at 48 months. The most common cause of death was cardiovascular problems (70%). ♢

CONCLUSIONS

In this clinical observational study, AAPD fulfilled its expected role, offering an opportune, reliable, and effective homecare alternative for ESRD patients with no other renal replacement therapy options.

O idoso em diálise

Em decorrência, principalmente, do envelhecimento populacional e mudanças no perfil epidemiológico, tem-se observado um crescente aumento do número de idosos em terapia renal substitutiva. O presente relato aponta e descreve os principais aspectos e as características do idoso em diálise; e destaca como imprescindível o atendimento em saúde, incluindo o cuidado de enfermagem, direcionado e especializado, diante das especificidades e necessidades desta parcela de pacientes nos centros de diálise.

Kidney in old age

Epidemiological studies have shown that chronic kidney disease (CKD) is a major health problem especially in an older population. Given the growing segment of the elderly population and the important implication of renal disease on health care, this review discusses the structural and functional changes of the ageing kidney and the underlying mechanisms of age-dependent injury. The implications of these changes in daily clinical practice and the management of CKD is also briefly overviewed.

Chronic peritoneal dialysis in the tenth decade of life

In this retrospective study we present our experience with chronic peritoneal dialysis in nine patients with ESRD in their 10th decade of life (> or =90 years) at the Toronto Western Hospital. A family member or a private nurse assisted all patients in dialysis procedure. The co-morbid illnesses, survival, hospitalizations and complications related or unrelated to peritoneal dialysis were reviewed. Four patients started dialysis before and five after their 90th birthday, their mean age was 90.61+/-4.04 years. All patients had three or more co-morbid illnesses at the start of dialysis. Total duration of PD treatment was 210 patient months with a median duration of 25 months (range 4-68 months). Of the nine patients, four died after a mean follow up of 38.5 months on dialysis. Of the remaining five, one was transferred to hemodialysis after remaining for 10 months on peritoneal dialysis and the other four are continuing on PD for a mean duration of 9.25 months. Peritonitis (1/13.4 patient months) and exit site infection (1/100.5 patient months) responded to treatment. Hospitalization rate was one admission per 2.5 patient years. Most often, the cause of hospitalization was unrelated to PD, e.g., cardiovascular events, pneumonia and peripheral vascular disease etc. Patient survival at 1, 3 and 5 years was 88%, 58% and 24% respectively. The technique survival was 69%, 47% and 23% at 1, 3 and 5 years respectively. We conclude that continuous peritoneal dialysis is a safe and suitable treatment even in nonagenarians (> or =90 years) ESRD patients.

Peritoneal dialysis in the nursing home

BACKGROUND

During the past few decades, the demographics of end stage renal disease have been changed significantly with the emerging predominance of elderly patients. Elderly dialysis patients are usually more dependent and may need long-term placement in a long-term care facility. Failure to meet the needs of these patients may have a significant impact on the peritoneal dialysis program. We report our experience of starting peritoneal dialysis program in a community-based Long Term Care Facility (LTCF).

METHODS

During the period of 2000-2001, after appropriate training of nursing home personnel, we admitted 8 peritoneal dialysis patients to one community-based nursing home. All information presented here has been collected through chart review.

RESULTS

At the time of admission the average age of the 8 patients was 77.3 +/- 7.2 years (range 69 to 91 years). All patients had several comorbid diseases and six of the eight were bed-ridden. The patients stayed in the facility for a total of 29.57 patient months. One patient had three episodes of peritonitis within three months (all culture negative) and has been excluded from the analysis of the overall peritonitis rate. The peritonitis rate for the other seven patients was 1 per 7.54 patient month. Six patients were readmitted to hospital because of peritonitis, severe malnutrition and hip fracture. Four of them died in the hospital. One died in the nursing home. One patient remains in the nursing home at the present time.

CONCLUSIONS

Our experience suggests that peritoneal dialysis can be achieved in a community-based nursing home. This requires a systematic training program for the LTCF personnel and the availability of a "dedicated" nephrology dialysis staff. This is crucial to the success of the program. It is important that patients, their families and ESRD care professionals are informed of the limited survival expectation particularly for very old and severely impaired patients.

Kidney function in older people: pathology, assessment and management

It is commonly not appreciated that kidney failure is predominantly a disease of older people and that the use of renal replacement therapy (RRT) amongst these patients is increasing rapidly. It is still unclear whether the decline in kidney function with increasing age represents pathology or is part of the normal ageing process. Conventional laboratory approaches to the assessment of kidney function in older people are inadequate, but the use of calculated clearance formulae and serum cystatin C can enable the earlier detection of chronic kidney disease (CKD) in this population. This could facilitate treatment aimed at reducing the progression of kidney disease in older people and improved management of its secondary complications.