Is self-care dialysis associated with social deprivation in a universal health care system? A cohort study with data from the Renal Epidemiology and Information Network Registry

Peritoneal dialysis versus haemodialysis for people commencing dialysis

BACKGROUND

Peritoneal dialysis (PD) and haemodialysis (HD) are two possible modalities for people with kidney failure commencing dialysis. Only a few randomised controlled trials (RCTs) have evaluated PD versus HD. The benefits and harms of the two modalities remain uncertain. This review includes both RCTs and non-randomised studies of interventions (NRSIs).

OBJECTIVES

To evaluate the benefits and harms of PD, compared to HD, in people with kidney failure initiating dialysis.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies from 2000 to June 2024 using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. MEDLINE and EMBASE were searched for NRSIs from 2000 until 28 March 2023.

SELECTION CRITERIA

RCTs and NRSIs evaluating PD compared to HD in people initiating dialysis were eligible.

DATA COLLECTION AND ANALYSIS

Two investigators independently assessed if the studies were eligible and then extracted data. Risk of bias was assessed using standard Cochrane methods, and relevant outcomes were extracted for each report. The primary outcome was residual kidney function (RKF). Secondary outcomes included all-cause, cardiovascular and infection-related death, infection, cardiovascular disease, hospitalisation, technique survival, life participation and fatigue.

MAIN RESULTS

A total of 153 reports of 84 studies (2 RCTs, 82 NRSIs) were included. Studies varied widely in design (small single-centre studies to international registry analyses) and in the included populations (broad inclusion criteria versus restricted to more specific participants). Additionally, treatment delivery (e.g. automated versus continuous ambulatory PD, HD with catheter versus arteriovenous fistula or graft, in-centre versus home HD) and duration of follow-up varied widely. The two included RCTs were deemed to be at high risk of bias in terms of blinding participants and personnel and blinding outcome assessment for outcomes pertaining to quality of life. However, most other criteria were assessed as low risk of bias for both studies. Although the risk of bias (Newcastle-Ottawa Scale) was generally low for most NRSIs, studies were at risk of selection bias and residual confounding due to the constraints of the observational study design. In children, there may be little or no difference between HD and PD on all-cause death (6 studies, 5752 participants: RR 0.81, 95% CI 0.62 to 1.07; I2 = 28%; low certainty) and cardiovascular death (3 studies, 7073 participants: RR 1.23, 95% CI 0.58 to 2.59; I2 = 29%; low certainty), and was unclear for infection-related death (4 studies, 7451 participants: RR 0.98, 95% CI 0.39 to 2.46; I2 = 56%; very low certainty). In adults, compared with HD, PD had an uncertain effect on RKF (mL/min/1.73 m2) at six months (2 studies, 146 participants: MD 0.90, 95% CI 0.23 to 3.60; I2 = 82%; very low certainty), 12 months (3 studies, 606 participants: MD 1.21, 95% CI -0.01 to 2.43; I2 = 81%; very low certainty) and 24 months (3 studies, 334 participants: MD 0.71, 95% CI -0.02 to 1.48; I2 = 72%; very low certainty). PD had uncertain effects on residual urine volume at 12 months (3 studies, 253 participants: MD 344.10 mL/day, 95% CI 168.70 to 519.49; I2 = 69%; very low certainty). PD may reduce the risk of RKF loss (3 studies, 2834 participants: RR 0.55, 95% CI 0.44 to 0.68; I2 = 17%; low certainty). Compared with HD, PD had uncertain effects on all-cause death (42 studies, 700,093 participants: RR 0.87, 95% CI 0.77 to 0.98; I2 = 99%; very low certainty). In an analysis restricted to RCTs, PD may reduce the risk of all-cause death (2 studies, 1120 participants: RR 0.53, 95% CI 0.32 to 0.86; I2 = 0%; moderate certainty). PD had uncertain effects on both cardiovascular (21 studies, 68,492 participants: RR 0.96, 95% CI 0.78 to 1.19; I2 = 92%) and infection-related death (17 studies, 116,333 participants: RR 0.90, 95% CI 0.57 to 1.42; I2 = 98%) (both very low certainty). Compared with HD, PD had uncertain effects on the number of patients experiencing bacteraemia/bloodstream infection (2 studies, 2582 participants: RR 0.34, 95% CI 0.10 to 1.18; I2 = 68%) and the number of patients experiencing infection episodes (3 studies, 277 participants: RR 1.23, 95% CI 0.93 to 1.62; I2 = 20%) (both very low certainty). PD may reduce the number of bacteraemia/bloodstream infection episodes (2 studies, 2637 participants: RR 0.44, 95% CI 0.27 to 0.71; I2 = 24%; low certainty). Compared with HD; It is uncertain whether PD reduces the risk of acute myocardial infarction (4 studies, 110,850 participants: RR 0.90, 95% CI 0.74 to 1.10; I2 = 55%), coronary artery disease (3 studies, 5826 participants: RR 0.95, 95% CI 0.46 to 1.97; I2 = 62%); ischaemic heart disease (2 studies, 58,374 participants: RR 0.86, 95% CI 0.57 to 1.28; I2 = 95%), congestive heart failure (3 studies, 49,511 participants: RR 1.10, 95% CI 0.54 to 2.21; I2 = 89%) and stroke (4 studies, 102,542 participants: RR 0.94, 95% CI 0.90 to 0.99; I2 = 0%) because of low to very low certainty evidence. Compared with HD, PD had uncertain effects on the number of patients experiencing hospitalisation (4 studies, 3282 participants: RR 0.90, 95% CI 0.62 to 1.30; I2 = 97%) and all-cause hospitalisation events (4 studies, 42,582 participants: RR 1.02, 95% CI 0.81 to 1.29; I2 = 91%) (very low certainty). None of the included studies reported specifically on life participation or fatigue. However, two studies evaluated employment. Compared with HD, PD had uncertain effects on employment at one year (2 studies, 593 participants: RR 0.83, 95% CI 0.20 to 3.43; I2 = 97%; very low certainty).

AUTHORS' CONCLUSIONS

The comparative effectiveness of PD and HD on the preservation of RKF, all-cause and cause-specific death risk, the incidence of bacteraemia, other vascular complications (e.g. stroke, cardiovascular events) and patient-reported outcomes (e.g. life participation and fatigue) are uncertain, based on data obtained mostly from NRSIs, as only two RCTs were included.

Is social deprivation associated with the peritoneal dialysis outcomes? A cohort study with REIN registry data

BACKGROUND

Social deprivation is associated with lower peritoneal dialysis (PD) uptake. This study was carried out to evaluate the role of social deprivation on the outcome of PD.

METHODS

This was a retrospective study of data extracted from the Renal Epidemiology and Information Network registry for patients older than 18 years who started PD in metropolitan France between 1 January 2017 and 30 June 2018. The end of the observation period was 31 December 2020. The exposure was the European Deprivation Index calculated using the patient's address. The events of interest were death, transfer to haemodialysis (HD), transplantation and the composite event of death or transfer to HD. A Cox model and Fine and Gray model were used for the analysis.

RESULTS

A total of 1581 patients were included, of whom 418 (26.5%) belonged to Quintile 5 of the European Deprivation Index (the most deprived patients). In the Cox model, the most deprived subjects did not have a greater risk of death (cause-specific hazard ratio (cs-HR): 0.76 [95% confidence interval (CI): 0.53-1.10], transfer to HD (cs-HR 1.37 [95% CI: 0.95-1.98]) or the composite event of death or transfer to HD (cs-HR: 1.08 [95% CI: 0.84-1.38]) or a lower risk of kidney transplantation (cs-HR: 0.73 [95% CI: 0.48-1.10]). In the competing risk analysis, the most deprived subjects had a higher risk of transfer to HD (subdistribution hazard ratio (sd-HR): 1.54 [95% CI: 1.08-2.19]) and lower access to kidney transplantation (sd-HR: 0.68 [0.46-0.99]).

CONCLUSION

In PD patients, social deprivation was not associated with death or the composite event of death or transfer to HD. Socially deprived individuals had a greater risk of transfer to HD and lower access to kidney transplantation in the competing risk analysis.

Sex disparities in the utilization of nurse-assisted peritoneal dialysis: a mediation analysis using data from the REIN registry

Background

This study was carried out to evaluate the association between patient sex and the proportion of nurse-assisted peritoneal dialysis (PD) at dialysis initiation and to explore whether sex disparities in nurse-assisted PD utilization was explained by predialysis care and/or by social deprivation using mediation analysis.

Methods

This was a retrospective study using data from the Renal Epidemiology and Information Network (REIN) registry linked to the French National Healthcare Database (SNDS) of incident patients between 1 January 2017 and 30 June 2018. A regression logistic was used for statistical analysis. A mediation analysis explored the direct effect of sex on nurse-assisted PD proportion and the indirect effect through the European Deprivation Index (EDI), and the number of general practitioner (GP) and nephrologist visits before dialysis initiation.

Results

Among 1706 patients on PD, there were 637 women (37.3%) and 1069 men (62.7%). Nurse-assisted PD proportion was 332/610 (54.4%) for women vs 464/1036 (44.8%) for men. In the multivariable analysis women were more likely to be treated by nurse-assisted PD {odds ratio (OR) 1.92 [95% confidence interval (CI) 1.46-2.52]}. Nurse-assisted PD was associated with the median number of GP visits [OR 1.44 (95% CI 1.11-1.86)] and with the median number of nephrologist visits [OR 0.59 (95% CI 0.46-0.76)]. The mediation analysis showed a direct effect of sex on nurse-assisted PD [OR 1.90 (95% CI 1.80-2.01)] and an indirect effect through the median number of GP visits [OR 1.05 (95% CI 1.04-1.06], the median number of nephrologist visits [OR 1.02 (95% CI 1.02-1.03)] and quintile 5 of the EDI [OR 1.03 (95% CI 1.02-1.03)].

Conclusion

Women were more frequently treated by nurse-assisted PD than men. Differences between women and men in predialysis care and social deprivation could explain the greater utilization of nurse-assisted PD among women.

Social deprivation and kidney failure due to an undiagnosed nephropathy

BACKGROUND

In France, kidney diseases of undetermined origin account for 5%-20% of all causes of end-stage kidney disease. We investigated the impact of social disadvantage on the lack of aetiological diagnosis of nephropathies.

METHODS

Data from patients who started dialysis in France between 1 January 2017 and 30 June 2018 were extracted from the French Renal Epidemiology and Information Network registry. The social deprivation of each individual was estimated by the European Deprivation Index (EDI) defined by the patient's address. Logistic regression was used to perform mediation analysis to study the potential association between social deprivation and unknown nephropathy.

RESULTS

Of the 7218 patients included, 1263 (17.5%) had unknown kidney disease. A total of 394 (31.4%) patients in the unknown kidney disease belonged to the most deprived quintile of the EDI [fifth quintile (Q5)], vs 1636 (27.5%) patients in the known kidney disease group. In the multivariate analysis, unknown kidney disease was associated with Q5 (odds ratio 1.40, 95% confidence interval 1.12-1.74, P = .003). Mediation analysis did not identify any variables (e.g. obesity, initiation of dialysis in emergency, number of visits to the general practitioner and nephrologist before initiation of dialysis, date of first nephrology consultation) that mediated the association between social deprivation and nephropathy of unknown origin.

CONCLUSIONS

Our results show that, compared with nondeprived subjects, individuals experiencing social deprivation have a higher risk of unknown nephropathy at dialysis initiation. However, mediation analysis did not identify any variables that explained the association between social deprivation and nephropathy of unknown origin.

[REIN: a tool to highlight inequalities in health]

On the occasion of the 20th anniversary of the REIN (French Renal Epidemiology and Information Network), a summary work on the contributions of the national French ESKD register was carried out. On the issue of Social Inequalities in Health, the following key messages were retained. Social inequalities in health exist throughout the journey of a patient with chronic kidney disease and manifest as territorial inequalities in access to home-based or independent dialysis treatment and to transplant, whether preemptive or otherwise. SIH are observed in adults as well as in the paediatric population. The female gender appears to be associated with a disparity in access to kidney transplant.

Systematic Review: Impact of Social Determinants of Health on the Management and Prognosis of Gallstone Disease

Background:

Due to its prevalence, gallstone disease is a major public health issue. It affects diverse patient populations across various socioeconomic levels. Socioeconomic and geographic deprivation may impact both morbidity and mortality associated with digestive diseases, such as biliary tract disease.

Aim:

The aim of this systematic review was to review the available data on the impact of socioeconomic determinants and geographic factors on gallstone disease and its complications.

Methods:

This systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The MEDLINE and Web of Science databases were searched by two investigators to retrieve studies about the impact of income, insurance status, hospital status, education level, living areas, and deprivation indices on gallstone disease. Thirty-seven studies were selected for this review.

Results:

Socially disadvantaged populations appear to be more frequently affected by complicated or severe forms of gallstone disease. The prognosis of biliary tract disease is poor in these populations regardless of patient status, and increased morbidity and mortality were observed for acute cholangitis or subsequent cholecystectomy. Limited or delayed access and low-quality therapeutic interventions could be among the potential causes for this poor prognosis.

Conclusions:

This systematic review suggests that socioeconomic determinants impact the management of gallstone disease. Enhanced knowledge of these parameters could contribute to improved public health policies to manage these diseases.

Is there sex disparity in vascular access at dialysis initiation in France? A mediation analysis using the data of the REIN registry

Background

This study was conducted to estimate the direct effect of sex on the proportion of hemodialysis catheters at dialysis initiation and to investigate whether predialysis care or socioeconomic status acted as a mediator of the sex effect.

Methods

Patients who started dialysis between 01–01-2017 and 30–06-2018 in France were included using the data of the REIN registry. Logistic regression was performed to study the association between sex and the proportion of HD catheters. A mediation analysis with a counterfactual approach was carried out to evaluate whether there was an indirect effect of gender through the proxies of predialysis care (hemoglobin, albumin levels, glomerular filtration rate (GFR) at dialysis initiation) and socioeconomic status. Due to the identification of an interaction between gender and social deprivation, a subgroup analysis was performed among deprived and nondeprived patients.

Results

There were 16 032 patients included, and the sex ratio (M/F) was 10 405/5627. In the multivariable analysis, women were associated with a greater risk of starting dialysis with a catheter (OR 1.32 [95% CI: 1.23–1.42]). There was an indirect effect of sex on the proportion of HD catheters through proxies for predialysis care (albuminemia < 30 g/L (OR 1.08 [95% CI: 1.05–1.10]), hemoglobin < 11 g/dL (OR 1.03 [95% CI: 1.02–1.04]), GFR < 7 ml/min (OR 1.05 [95% CI: 1.04–1.07])). Among deprived patients, there was no direct effect of sex on the catheter proportion.

Conclusions

Women were associated with a higher risk of starting dialysis through an HD catheter. The effect of sex was mediated by predialysis care, particularly for deprived patients.

Dialysis-network variability in home dialysis use not explained by patient characteristics: a national registry-based cohort study in France

Background

Although associated with better quality of life and potential economic advantages, home dialysis use varies greatly internationally and appears to be underused in many countries. This study aimed to estimate the dialysis-network variability in home dialysis use and identify factors associated with 1) the uptake in home dialysis, 2) the proportion of time spent on home dialysis and 3) home dialysis survival (patient and technique).

Methods

All adults ≥ 18 years old who had dialysis treatment during 2017-2019 in mainland France were included. Mixed-effects regression models were built to explore factors including patient or residence characteristics and dialysis network associated with variation in home dialysis use.

Results

During 2017-2019, 7 728/78 757 (9.8%) patients underwent dialysis at least once at home for a total of 120 594/ 1 508 000 (8%) months. The heterogeneity at the dialysis-network level and to a lesser extent the regional level regarding home dialysis uptake or total time spent was marginally explained by patient characteristics or residence and dialysis-network factors. Between-network heterogeneity was less for patient and technique survival. These results were similar when the analysis was restricted to home peritoneal dialysis or home hemodialysis.

Conclusions

Variability between networks in the use of home dialysis was not fully explained by non-modifiable patient and residence characteristics. Our results suggest that to increase home dialysis use in France, one should focus on home dialysis uptake rather than survival. Financial incentives and a quality improvement program should be implemented at the dialysis-network level to increase home dialysis use.

Effects of Social Deprivation on the Proportion of Preemptive Kidney Transplantation: A Mediation Analysis

Social inequalities in health lead to an increased risk of chronic kidney disease and less access to renal transplantation. The objective of this study was to assess the association between social deprivation estimated by the fifth quintile of the European Deprivation Index (EDI) and preemptive kidney transplantation (PKT) and to explore the potential mediators of this association.

Methods

This retrospective observational multicenter study included 8701 patients who received their first renal transplant in France between 2010 and 2014. Mediation analyses were performed to assess the direct and indirect effects of the EDI on PKT.

Results

Among the 8701 transplant recipients, 32.4% belonged to the most deprived quintile of the EDI (quintile 5) and 16% received a PKT (performed either with a deceased- or living-donor). There was a significant association between quintile 5 of the EDI and PKT (total effect: odds ratio [OR]: 0.64 [95% confidence interval (CI): 0.55-0.73]). Living-donor kidney transplantation was the main mediator of this association (natural indirect effect: OR: 0.92 [0.89-0.95]). To a lesser extent, positive cytomegalovirus and hepatitis C serologies and blood group B were also mediators (respective natural indirect effects: OR: 0.98 [95% CI: 0.95-1.00], OR: 0.99 [95% CI: 0.99-1.00], and OR: 0.99 [95% CI: 0.98-1.00], P < 0.05).

Conclusions

Our study suggests that social deprivation is associated with a decreased proportion of PKT. This association might be mitigated by promoting living-donor transplantation.

Effect of social deprivation on peritoneal dialysis uptake: A mediation analysis with the data of the REIN registry

BACKGROUND

Social deprivation could act as a barrier to peritoneal dialysis (PD). The objective of this study was to assess the association between social deprivation estimated by the European deprivation index (EDI) and PD uptake and to explore the potential mediators of this association.

METHODS

From the Renal Epidemiology and Information Network registry, patients who started dialysis in 2017 were included. The EDI was calculated based on the patient's address. The event of interest was the proportion of PD 3 months after dialysis initiation. A mediation analysis with a counterfactual approach was carried out to evaluate the direct and indirect effect of the EDI on the proportion of PD.

RESULTS

Among the 9588 patients included, 1116 patients were on PD; 2894 (30.2%) patients belonged to the most deprived quintile (Q5). PD was associated with age >70 years (odds ratio (OR) 0.79 [95% confidence interval (CI): 0.69-0.91]), male gender (0.85 [95% CI: 0.74-0.97]), cardiovascular disease (OR 0.86 [95% CI: 0.86-1.00]), chronic heart failure (OR 1.34 [95% CI: 1.13-1.58]), active cancer (OR 0.67 [95% CI: 0.53-0.85]) and obesity (OR 0.75 [95% CI: 0.63-0.89]). In the mediation analysis, Q5 had a direct effect on PD proportion OR 0.84 [95% CI: 0.73-0.96]. The effect of Q5 on the proportion of PD was mediated by haemoglobin level at dialysis initiation (OR 0.96 [95% CI: 0.94-0.98]) and emergency start (OR 0.98 [95% CI: 0.96-0.99]).

CONCLUSION

Social deprivation, estimated by the EDI, was associated with a lower PD uptake. The effect of social deprivation was mediated by haemoglobin level, a proxy of predialysis care and emergency start.