Treatment of chronic kidney disease in older populations

As the world population ages, an expected increase in the prevalence of chronic kidney disease (CKD) among older individuals will pose a considerable challenge for health care systems in terms of resource allocation for disease management. Treatment strategies for older patients with CKD should ideally align with those applied to the general population, focusing on minimizing cardiovascular events and reducing the risk of progression to kidney failure. Emerging therapies, such as SGLT-2 inhibitors and GLP-1 receptor agonists, hold promise for the effective management of CKD in older individuals. In addition, non-pharmacological interventions such as nutritional and exercise therapies have a crucial role. These interventions enhance the effects of pharmacotherapy and, importantly, contribute to the maintenance of cognitive function and overall quality of life. Various factors beyond age and cognitive function must be taken into account when considering kidney replacement therapy for patients with kidney failure. Importantly, all treatment options, including dialysis, transplantation and conservative management approaches, should be tailored to the individual through patient-centred decision-making. The dynamic integration of digital technologies into medical practice has the potential to transform the management of CKD in the aging population.

The impact of quality of life on the survival of elderly patients with end-stage renal disease: a prospective multicenter cohort study in Korea

Background

Quality of life (QOL) is associated with mortality in dialysis patients. However, the impact of QOL index or score on elderly patients undergoing maintenance dialysis is unclear. We analyzed the relationship between QOL domains and survival in elderly end-stage renal disease (ESRD) patients on dialysis.

Methods

We included 492 incident ESRD patients aged ≥65 years from a Korean nationwide prospective cohort study who were assessed for QOL with a follow-up duration of 67.3 ± 34.6 months after dialysis initiation. Their QOL was evaluated using the Kidney Disease Quality of Life (KDQOL) instrument, and the effect of each QOL domain on mortality was analyzed. Multivariable Cox regression analysis was performed to identify independent risk factors for death after adjusting for confounding factors.

Results

Low physical component summary (PCS) and Short Form-36 score were significantly associated with low survival rate (P < .001 and P = .017, respectively), whereas the mental component summary and ESRD-targeted item scores were not correlated with survival rate. Multivariable Cox regression analysis confirmed that only a high PCS score was associated with better survival (hazard ratio 0.71; 95% confidence interval 0.52-0.97; P = .031). Linear regression analysis revealed that age, sex, modified Charlson comorbidity index, albumin and intact parathyroid hormone were associated with PCS. Among the PCS items, only the physical functioning score was significantly associated with mortality (P = .017).

Conclusion

PCS was an independent risk factor for death in elderly ESRD patients. A higher physical functioning score was associated with a better outcome, suggesting the importance of physical condition in elderly dialysis patients.

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.

Towards a better uptake of home dialysis in Europe: understanding the present and looking to the future

Use of peritoneal dialysis and home haemodialysis remains low in Europe, with the highest use in Scandinavian countries and the lowest in Eastern and Central Europe despite the advantages for people on dialysis and economic advantages for healthcare systems. This is partly due to the impact of the haemodialysis industry resulting in proliferation of haemodialysis units and nephrologist reimbursement related to use of haemodialysis. Equally important is the bias against home dialysis at both clinician and healthcare system levels. The underlying causes of this bias are discussed in relation to a mechanistic view of the human body, lack of compassion, failure to adjust dialysis provision for older age and frailty, proliferation of small dialysis centres, and complexity of decision-making and clinical care. For home dialysis to flourish, we need to foster a change in attitude to and vision of the aims of healthcare so that enabling meaningful activities of people requiring dialysis, as explored in the Standardized Outcomes in Nephrology initiative, rather than achieving biological numbers become the focus of care delivery.

Shared decision making in elderly patients with kidney failure

'Elderly' is most commonly defined as an individual aged 65 years or older. However, this definition fails to account for the differences in genetics, lifestyle and overall health that contribute to significant heterogeneity among the elderly beyond chronological age. As the world population continues to age, the prevalence of chronic diseases, including chronic kidney disease (CKD), is increasing and CKD frequently progresses to kidney failure. Moreover, frailty represents a multidimensional clinical entity highly prevalent in this population, which needs to be adequately assessed to inform and support medical decisions. Selecting the optimal treatment pathway for the elderly and frail kidney failure population, be it haemodialysis, peritoneal dialysis or conservative kidney management, is complex because of the presence of comorbidities associated with low survival rates and impaired quality of life. Management of these patients should involve a multidisciplinary approach including doctors from various specialties, nurses, psychologists, dieticians and physiotherapists. Studies are mostly retrospective and observational, lacking adjustment for confounders or addressing selection and indication biases, making it difficult to use these data to guide treatment decisions. Throughout this review we discuss the difficulty of making a one-size-fits-all recommendation for the clinical needs of older patients with kidney failure. We advocate that a research agenda for optimization of the critical issues we present in this review be implemented. We recommend prospective studies that address these issues, and systematic reviews incorporating the complementary evidence of both observational and interventional studies. Furthermore, we strongly support a shared decision-making process matching evidence with patient preferences to ensure that individualized choices are made regarding dialysis vs conservative kidney management, dialysis modality and optimal vascular access.

Mortality of Peritoneal Dialysis versus Hemodialysis in Older Adults: An Updated Systematic Review and Meta-Analysis

INTRODUCTION

The optimal choice of dialysis modality remains contentious in older adults threatened by advanced age and high risk of comorbidities.

METHODS

We conducted a systematic review and meta-analysis of cohort and case-control studies to assess mortality risk between peritoneal dialysis (PD) and hemodialysis (HD) in older adults using PubMed, Embase, and the Cochrane Library database from inception to June 1, 2022. The outcome of interest is all-cause mortality.

RESULTS

Thirty-one eligible studies with >774,000 older patients were included. Pooled analysis showed that PD had a higher mortality rate than HD in older dialysis population (HR 1.17, 95% CI: 1.10-1.25). When stratified by co-variables, our study showed an increased mortality risk of PD versus HD in older patients with diabetes mellitus or comorbidity who underwent longer dialysis duration (more than 3 years) or who started dialysis before 2010. However, definitive conclusions were constrained by significant heterogeneity.

CONCLUSION

From the survival point of view, caution is needed to employ PD for long-term use in older populations with diabetes mellitus or comorbid conditions. However, a tailored treatment choice needs to take account of what matters to older adults at an individual level, especially in the context of limited survival improvements and loss of quality of life. Further research is still awaited to conclude this topic.

All-Cause Standardized Mortality Ratio in Hemodialysis and Peritoneal Dialysis Patients: A Nationwide Population-Based Cohort Study

Patients with end-stage renal disease (ESRD) are at a higher mortality risk compared with the general population. Previous studies have described a relationship between mortality and patients with ESRD, but the data on standardized mortality ratio (SMR) corresponding to different causes of death in patients undergoing hemodialysis (HD) and peritoneal dialysis (PD) are limited. This study was designed as a nationwide population-based retrospective cohort study. Incident dialysis patients between January 2000 and December 2015 in Taiwan were included. Using data acquired from the Taiwan Death Registry, SMR values were calculated and compared with the overall survival. The results showed there were a total of 128,966 patients enrolled, including 117,376 incident HD patients and 11,590 incident PD patients. It was found that 75,297 patients (58.4%) died during the period of 2000-2017. The overall SMR was 5.21. The neoplasms SMR was 2.11; the endocrine, nutritional, metabolic, and immunity disorders SMR was 13.53; the circulatory system SMR was 4.31; the respiratory system SMR was 2.59; the digestive system SMR was 6.1; and the genitourinary system SMR was 27.22. Therefore, more attention should be paid to these diseases in clinical care.

A novel programme of supportive two-exchange assisted continuous ambulatory peritoneal dialysis for frail patients with end-stage kidney disease

We have developed a supportive two-exchange assisted continuous ambulatory peritoneal dialysis (asCAPD) programme for the older frail person who cannot do autonomous PD and do not want or are considered to be too high risk for haemodialysis (HD). Evaluation of the programme was determined by data collected retrospectively from patient records. Primary outcome was comparison of symptoms at start of dialysis and 3 months following dialysis start. Secondary outcomes were survival and peritonitis rate. Over a 4-year period (2016-2020), 49 patients with mean age 79.6 years (range 47-90) enrolled in the programme with eGFR 7.7 ± 2.6 ml/min (mean ± SD) at dialysis start. Forty-one patients had been on asCAPD for >3 months. There was an improvement in all symptoms at 3 months compared to baseline: anorexia (46% to 15%), fatigue (46% to 15%), shortness of breath (27% to 2%) and oedema (51% to 32%). One-year survival was 55%. Peritonitis rate was 0.52 episodes per patient year. The novel supportive two-exchange asCAPD programme shows potential improvement of symptoms after 3 months and may provide an acceptable dialysis modality for the frail co-morbid person with established kidney failure. More detailed study and evaluation are needed.

Device-assisted continuous ambulatory peritoneal dialysis: A single-centre experience

BACKGROUND

Peritoneal dialysis (PD) patients with impaired hand-eye function require helper assistance. Our centre developed a connection device that assists patients with impaired hand-eye function to perform PD exchange themselves, but the clinical outcomes in these patients have not been investigated.

METHODS

We retrospectively reviewed patients who had device-assisted continuous ambulatory peritoneal dialysis (CAPD) during 2007-2016 and compared their clinical outcomes with age- and sex-matched patients receiving helper-assisted CAPD.

RESULTS

One hundred seventy-two patients (86 each in the device- and helper-assisted CAPD groups) were followed for 29.9 (19.4-43.3) months. The device- and helper-assisted groups had comparable peritonitis rates (0.489 and 0.504 episode per patient-year, respectively, p = 0.814), with no difference in the distribution of causative organisms and the organism-specific peritonitis rates. The device-assisted group showed similar peritonitis-free survival compared with the helper-assisted group (2.58 (1.85-3.31) vs. 1.78 (0.68-2.88) years, p = 0.363) and time-to-PD discontinuation (6.27 (3.65-8.90) vs. 4.35 (3.48-5.22) years, p = 0.677). The median patient survival was similar between the two groups (3.89 (2.22-5.55) vs. 3.81 (3.27-4.36) years in the device- and helper-assisted groups, respectively, p = 0.505).

CONCLUSION

Device-assisted CAPD confers comparable outcomes as helper-assisted CAPD and is a viable option in PD patients with impaired hand-eye function.

Hemodialysis and Peritoneal Dialysis in Germany from a Health Economic View-A Propensity Score Matched Analysis

BACKGROUND

Hemodialysis (HD) and peritoneal dialysis (PD) are deemed medically equivalent for therapy of end-stage renal disease (ESRD) and reimbursed by the German statutory health insurance (SHI). However, although the home dialysis modality PD is associated with higher patient autonomy than HD, for unknown reasons, PD uptake is low in Germany. Hence, we compared HD with PD regarding health economic outcomes, particularly costs, as potentially relevant factors for the predominance of HD.

METHODS

Claims data from two German health insurance funds were analysed in a retrospective cohort study regarding the prevalence of HD and PD in 2013-2016. Propensity score matching created comparable HD and PD groups (n = 436 each). Direct annual health care costs were compared. A sensitivity analysis included a comparison of different matching techniques and consideration of transportation costs. Additionally, hospitalisation and survival were investigated using Poisson regression and Kaplan-Meier curves.

RESULTS

Total direct annual average costs were higher for HD (€47,501) than for PD (€46,235), but not significantly (p = 0.557). The additional consideration of transportation costs revealed an annual cost advantage of €7000 for PD. HD and PD differed non-significantly in terms of hospitalisation and survival rates (p = 0.610/p = 0.207).

CONCLUSIONS

PD has a slight non-significant cost advantage over HD, especially when considering transportation costs.

Differences in hospitalisation between peritoneal dialysis and haemodialysis patients

BACKGROUND

Dialysis is associated with frequent hospitalisations. Studies comparing hospitalisations between peritoneal dialysis (PD) and haemodialysis (HD) report conflicting results and mostly analyse data of patients that remain on their initial dialysis modality. This cohort study compares hospitalisations between PD and HD patients taking into account transitions between modalities.

METHODS

The Dutch nOcturnal and hoME dialysis Study To Improve Clinical Outcomes collected hospitalisation data of patients who started dialysis between 2012 and 2017. Primary outcome was hospitalisation rate, analysed with a multi-state model that attributed each hospitalisation to the current dialysis modality.

RESULTS

In total, 695 patients (252 PD, 443 HD) treated in 31 Dutch hospitals were included. The crude hospitalisation rate for PD was 2.3 ( ± 5.0) and for HD 1.4 ( ± 3.2) hospitalisations per patient-year. The adjusted hazard ratio for hospitalisation rate was 1.1 (95%CI 1.02-1.3) for PD compared with HD. The risk for first hospitalisation was 1.3 times (95%CI 1.1-1.6) higher for PD compared with HD during the first year after dialysis initiation. The number of hospitalisations and number of hospital days per patient-year were significantly higher for PD. The most common causes of PD and HD hospitalisations were peritonitis (23%) and vascular access-related problems (33%).

CONCLUSION

PD was associated with higher hospitalisation rate, higher risk for first hospitalisation and higher number of hospitalisations compared with HD. Since the PD hospitalisations were mainly caused by peritonitis, more attention to infection prevention is necessary for reducing the number of hospitalisations in the future.

Microbiology and Outcome of Peritoneal Dialysis-Related Peritonitis in Elderly Patients: A Retrospective Study in China

Objective

The number of elderly patients on peritoneal dialysis (PD) has rapidly increased in the past few decades. We sought to explore the microbiology and outcomes of peritonitis in elderly PD patients compared with younger PD patients.

Methods

We conducted a retrospective study to analyze the clinical characteristics, causative organism distribution, and outcome of all PD patients who developed peritonitis between September 1, 2014 and December 31, 2020, from Second Xiangya Hospital, Central South University, China. Patients who experienced peritonitis were separated into elderly and younger groups. The elderly was defined as ≥ 65 years old at the initiation of PD.

Results

Among 1,200 patients, 64(33.9%) in elderly (n = 189) and 215 (21.3%) in younger (n = 1,011) developed at least one episode of peritonitis. A total of 394 episodes of peritonitis occurred in 279 patients. Of these, 88 episodes occurred in 64 elderly patients, and 306 episodes occurred in 215 younger patients. Gram-positive bacteria were the main causative organisms in elderly and younger patients (43.2% and 38.0%, respectively). Staphylococcus and Escherichia coli were the most common gram-positive and gram-negative bacteria, respectively. Fungal peritonitis in elderly patients was higher compared with younger patients (χ2 = 6.55, P = 0.01). Moreover, Acinetobacter baumannii (χ ²=9.25, P = 0.002) and polymicrobial peritonitis (χ ² = 6.41, P = 0.01) in elderly patients were also significantly higher than that in younger patients. Additionally, elderly PD patients had higher peritonitis-related mortality than younger patients (χ ² = 12.521, P = 0.000), though there was no significant difference in catheter removal between the two groups. Kaplan-Meier analysis showed that cumulative survival was significantly lower in elderly patients than younger patients (log rank = 7.867, p = 0.005), but similar technical survival in both groups (log rank = 0.036, p = 0.849).

Conclusions

This retrospective study demonstrated that elderly PD patients were more likely to develop Acinetobacter baumannii, fungal and polymicrobial peritonitis than younger PD patients. In addition, peritonitis-related mortality was significantly higher in elderly patients, whereas peritonitis-related catheter removal was comparable between elderly and younger PD patients. Understanding microbiology and outcome in elderly patients will help to reduce the incidence of PD-associated peritonitis and improve the quality of life.

Safety of peritoneal dialysis catheter surgery under dexmedetomidine and local anesthesia for elderly patients in Japan: a single-center prospective cohort study

BACKGROUND

The number of patients aged ≥ 75 years and who need renal replacement therapy is steadily increasing. The study aimed to determine the safety of open surgery for peritoneal dialysis (PD) catheter placement in such patients.

METHODS

This prospective cohort study included patients who underwent PD catheter placement by open surgery under dexmedetomidine (DEX) and local anesthesia at our institution from January 2015 to February 2021. Patients were divided into the following two groups according to age at the time of surgery: ≥ 75 years (group A) and < 75 years (group B). We compared the perioperative and postoperative complications (i.e., time to the first PD-related peritonitis and catheter obstruction requiring surgical intervention within 1 year) between the groups.

RESULTS

A total of 118 patients were categorized into groups A (n = 65) and B (n = 53). No significant intergroup differences were observed in the postoperative fever, total duration of surgery, perioperative hemoglobin decrease, changes in the white blood cell count and C-reactive protein, postoperative catheter leakage, postoperative hospital stay, time to the first PD-related peritonitis, and catheter obstruction requiring surgical intervention within 1 year.

CONCLUSIONS

The surgery for PD catheter placement by open surgery under DEX and local anesthesia in elderly patients is safe and effective.

The case for Increased Peritoneal Dialysis Utilization in Low- and Lower-Middle-Income Countries

Peritoneal dialysis (PD) has several advantages compared to hemodialysis (HD), but there is evidence showing underutilization globally, especially in low-income and lower-middle-income countries (LLMICs) where kidney replacement therapies (KRT) are often unavailable, inaccessible, and unaffordable. Only 11% of all dialysis patients worldwide use PD, more than 50% of whom live in China, the United States of America, Mexico, or Thailand. Various barriers to increased PD utilization have been reported worldwide including patient preference, low levels of education, and lower provider reimbursement. However, unique but surmountable barriers are applicable to LLMICs including the excessively high cost of providing PD (related to PD fluids in particular), excessive cost of treatment borne by patients (relative to HD), lack of adequate PD training opportunities for doctors and nurses, low workforce availability for kidney care, and challenges related to some PD outcomes (catheter-related infections, hospitalizations, mortality, etc.). This review discusses some known barriers to PD use in LLMICs and leverages data that show a global trend in reducing rates of PD-related infections, reducing rates of modality switches from HD, and improving patient survival in PD to discuss how PD use can be increased in LLMICs. We therefore, challenge the idea that low PD use in LLMICs is unavoidable due to these barriers and instead present opportunities to improve PD utilization in LLMICs.

Smoothing transition to dialysis to improve early outcomes after dialysis initiation among old and frail adults-a narrative review

The number of patients ≥65 years of age suffering from advanced chronic kidney disease and transitioning to end-stage kidney disease (ESKD) is increasing. However, elderly patients often have poor outcomes once haemodialysis is initiated, including high mortality within the first year as well as fast cognitive and functional decline and diminished quality of life. The question is how we can smooth this transition to ESKD in older patients who also exhibit much higher proportions of frailty when compared with community-dwelling non-dialysis older adults and who are generally more vulnerable to invasive treatment such as kidney replacement therapy. To avoid early death and poor quality of life, a carefully prepared smooth transition should precede the initiation of treatment. This involves pre-dialysis physical and educational care, as well as mental and psychosocial preparedness of the patient to enable an informed and shared decision about the individual choice of treatment modality. Communication between a healthcare professional and patient plays a pivotal role but can be challenging given the high rate of cognitive impairment in this particular population. In order to practise patient-centred care, adapting treatment tailored to the individual patient should include comprehensive conservative care. However, structured treatment pathways including multidisciplinary teams for such conservative care are still rare and may be difficult to establish outside of large cities. Generally, geriatric nephrology misses data on the comparative effectiveness of different treatment modalities in this population of old and very old age on which to base recommendations and decisions.

Predictors of Health Deterioration Among Older New Zealanders Undergoing Dialysis: A Three-Year Accelerated Longitudinal Cohort Study

Background:

Patient involvement in dialysis decision-making is crucial, yet little is known about patient-reported outcomes over time on dialysis.

Objective:

To examine health-related outcomes over 24 and 36 months in an older cohort of dialysis patients.

Design:

The “Dialysis outcomes in those aged ≥65 years study” is a prospective longitudinal cohort study of New Zealanders with kidney failure.

Setting:

Three New Zealand nephrology units.

Patients:

Kidney failure (dialysis and predialysis) patients aged 65 or above. We have previously described outcomes after 12 months of dialysis therapy relative to baseline.

Measurements:

Patient-reported social and health factors using the SF-36, EQ-5D, and Kidney Symptom Score questionnaires.

Methods:

This article describes and compares characteristics of 120 older kidney failure patients according to whether they report “Same/better” or “Worse” health 24 and 36 months later, and identifies predictors of “worse health.” Modified Poisson regression modeling estimated relative risks (RR) of worse health.

Results:

Of 120 patients at 12 months, 47.5% had worse health or had died by 24 months. Of those surviving at 24 months (n = 80), 40% had “Worse health” or had died at 36 months. Variables independently associated with reduced risk of “Worse health” (24 months) were as follows: Māori ethnicity (RR = 0.44; 95% CI = 0.26-0.75), Pacific ethnicity (RR = 0.39; 95% CI = 0.33-0.46); greater social satisfaction (RR = 0.57; 95% CI = 0.46-0.7). Variables associated with an increased risk of “Worse health” were as follows: problems with usual activities (RR = 1.32; 95% CI = 1.04-1.37); pain or discomfort (RR = 1.48; 95% CI = 1.34, 1.63). At 36 months, lack of sense of community (RR = 1.41; 95% CI = 1.18-1.69), 2 or more comorbidities (RR = 1.21; 95% CI = 1.13-1.29), and problems with poor health (RR = 1.47; 95% CI = 1.41-1.54) were associated with “Worse health.”

Limitations:

Participant numbers restricted the number of variables able to be included in the multivariable model, and hence there may have been insufficient power to detect certain associations.

Conclusions:

In this study, the majority of older dialyzing patients report “Same/better health” at 24 and 36 months. Māori and Pacific people report better outcomes on dialysis. Social and/or clinical interventions aimed at improving social satisfaction, sense of community, and help with usual activities may impact favorably on the experiences for older dialysis patients.

Trial registration:

Australian and New Zealand clinical trials registry: ACTRN12611000024943.

Barriers to Peritoneal Dialysis in Saskatchewan Canada: Results From a Province-Wide Survey

Background:

Peritoneal dialysis (PD) is an underutilized, therapeutic option to in-center hemodialysis (HD), given its similar survival and clinical efficacy but provides lifestyle benefits and cost savings. Despite these advantages, PD prevalence rates remains below 20% in many Canadian jurisdictions.

Objectives:

The primary objective of this study was to identify and assess patient-perceived barriers to PD implementation in Saskatchewan. The secondary objectives were to examine variations in patient-perceived barriers to PD by dialysis units (main dialysis units vs satellite dialysis units) and specific challenges faced by First Nation patients residing on reserves.

Design:

A cross-sectional observational survey study.

Setting:

Two major centers (Regina and Saskatoon) and 5 associated satellite units attached to each center across the province of Saskatchewan.

Patients:

We approached all prevalent in-center HD patients across Saskatchewan, 366 (49%) agreed to participate in the study.

Measurements:

Self-reported barriers to PD were assessed using a 26-question survey which was created after engagement of our multidisciplinary team.

Methods:

We conducted a cross-sectional survey of 740 prevalent in-center HD patients within the province of Saskatchewan, Canada, from June 2018 to January 2019. Around 366 (49%) patients agreed to participate in the study. The questionnaire was designed to capture patients’ perceived barriers to PD. Descriptive statistics were used to present the data. Chi-square and Mann-Whitney U-test were used to compare the patients’ responses (main dialysis units vs satellite dialysis units, and First Nation reserves vs nonreserves).

Results:

Of the 366 patients who completed the survey, 284 met the eligibility criteria and were included in the analysis. Patient-reported satisfaction with current in-center HD care was the most common barrier to PD uptake (92%), followed by proximity to their HD unit (61%). A lack of understanding of the benefits/risks of PD, fear of family burden (54% each), and unwillingness to dialyze daily and to learn a new technique (51% each) were additional factors. Patients residing on reserves compared to nonreserve residents felt PD had a higher risk of infection compared to HD (54% vs 34%, P = .005), and felt PD led to suboptimal care (47% vs 31%, P = .021).

Limitations:

We used a nonstandardized locally derived questionnaire to quantify barriers, and this prevents inclusion of additional barriers than individual patients may consider important. Cross-sectional data can only be used as a snapshot. Only 366 patients agreed to participate, and the results cannot be generalized to 740 prevalent HD patients. We did not capture data on demographics (age, income, and literacy level), comorbidities, and dialysis vintage, which would have been helpful in interpretation of the results. We did not involve patients, carers, or patients of First Nations heritage, in the design of the survey and the study.

Conclusions:

The results of our survey indicate that the major patient-reported barrier to PD uptake in our province is clinical inertia in patients defaulted to in-center HD at the onset of dialysis. Lack of patient awareness and knowledge of PD as a viable treatment modality also figured prominently, as did fears/concerns surrounding the safety, efficacy, and perceived family burden with PD compared with in-center HD.

Trial Registration:

The study was not registered on a publicly accessible registry because it did not involve any health care intervention on human participants.

Good Patient and Technique Survival in Elderly Patients on Continuous Ambulatory Peritoneal Dialysis

The aging population has significant implications for the community. The increasing number of elderly end-stage renal disease (ESRD) patients presses the renal team to find an appropriate management plan. We used a retrospective analysis to study the effectiveness of continuous ambulatory peritoneal dialysis (CAPD) in elderly ESRD patients. Of the 328 CAPD patients recruited for the study, 121 were in the elderly group (≥ 65 years of age), and 207 were in the control group (under 65 years of age). Median age in the elderly group was 71 years, and in the control group, 51 years. The elderly group had a higher prevalence (54.5%) of diabetes mellitus. The 2-year and 5-year rates of patient survival were 89.3% and 54.8% respectively in the elderly group and 92.2% and 62.9% in the control group ( p = 0.19). The 2-year and 5-year rates of technique survival were 84.0% and 45.7% respectively in the elderly group and 80.9% and 49.1% in the control group ( p = 0.75). The probability of a 12-month peritonitis-free period was 76.6% in the elderly group and 76.5% in the control group ( p = 0.75).

One hundred elderly patients (82.6% of the group) performed their CAPD exchanges by themselves. We observed no significant difference in clinical outcome—including patient survival, technique survival, and peritonitis-free period—between the elderly self-care CAPD and the elderly assisted CAPD groups.

In elderly ESRD patients, CAPD is an effective dialysis modality. A slightly longer training time is to be expected for elderly patients. Self-care CAPD for elderly patients who are capable of performing their own exchanges provides them with an independent home life.

A Comparison of Patient-Reported Outcome Measures of Quality of Life By Dialysis Modality in the Treatment of Kidney Failure: A Systematic Review

Background:

There is an increasing demand to incorporate patient-reported outcome measures (PROMs) such as quality of life (QOL) in decision-making when selecting a chronic dialysis modality.

Objective:

To compare the change in QOL over time among similar patients on different dialysis modalities to provide unique and novel insights on the impact of dialysis modality on PROMs.

Design:

Systematic reviews, randomized controlled trials, and nonrandomized controlled trials were examined via a comprehensive search strategy incorporating multiple bibliographic databases.

Setting:

Data were extracted from relevant studies from January 1, 2000 to December 31, 2019 without limitations on country of study conduction.

Patients:

Eligible studies included adults (≥18 years) with end-stage kidney disease of any cause who were prescribed dialysis treatment (either as lifetime treatment or bridge to transplant).

Measurements:

The 5 comparisons were peritoneal dialysis (PD) vs in-center hemodialysis (ICHD), home hemodialysis (HHD) vs ICHD, HHD modalities compared with one another, HHD vs PD, and self-care ICHD vs traditional nurse-based ICHD.

Methods:

Included studies compared adults on different dialysis modalities with repeat measures within individuals to determine changes in QOL between dialysis modalities (in-center or home dialysis). Methodological quality was assessed by the Scottish Intercollegiate Guidelines Network (SIGN 50) checklist. A narrative synthesis was conducted, synthesizing the direction and size of any observed effects across studies.

Results:

Two randomized controlled trials and 9 prospective cohort studies involving a combined total of 3711 participants were included. Comparing PD and ICHD, 5 out of 9 studies found significant differences (P < .05) favoring PD in the change of multiple QOL domains, including “physical component score,” “role of social component score,” “cognitive status,” “role limitation due to emotional function,” “role limitation due to physical function,” “bodily pain,” “burden of kidney disease,” “effects of kidney disease on daily life,” “symptoms/problems,” “sexual function,” “finance,” and “patient satisfaction.” Conversely, 3 of these studies demonstrated statistically significant differences (P < .05) favoring ICHD in the domains of “role limitation due to physical function,” “general health,” “support from staff,” “sleep quality,” “social support,” “health status,” “social interaction,” “body image,” and “overall health.” Comparing HHD and ICHD, significant differences (P < .05) favoring HHD for the QOL domains of “general health,” “burden of kidney disease,” and the visual analogue scale were reported.

Limitations:

Our study is constrained by the small sample sizes of included studies, as well as heterogeneity among both study populations and validated QOL scales, limiting inter-study comparison.

Conclusions:

We identified differences in specific QOL domains between dialysis modalities that may aid in patient decision-making based on individual priorities.

Trial registration:

PROSPERO Registration Number: CRD42016046980.

Primary funding source:

The original research for this study was derived from the Canadian Agency for Drugs and Technologies in Health (CADTH) 2017 optimal use report, titled “Dialysis Modalities for the Treatment of End-Stage Kidney Disease: A Health Technology Assessment.” The CADTH receives funding from Canada’s federal, provincial, and territorial governments, with the exception of Quebec.

Comparisons of quality of life between patients underwent peritoneal dialysis and hemodialysis: a systematic review and meta-analysis

OBJECTIVE

End-stage renal disease (ESRD) leads to renal replacement therapy and certainly has an impact on patients' health-related quality of life (HRQoL). This study aimed to review and compare the HRQoL between peritoneal dialysis (PD) and hemodialysis (HD) patients using the 36-Item Short Form Health Survey (SF-36), EuroQoL-5-dimension (EQ-5D) and the Kidney Disease Quality of Life Instrument (KDQOL).

METHODOLOGY

Systematic review was conducted by identify relevant studies through MEDLINE and SCOPUS up to April 2017. Studies were eligible with following criteria: studied in ESRD patients, compare any pair of renal replacement modalities, and reported HRQoL. The unstandardized mean differences (USMD) of HRQoL among modalities were calculated and pooled using a random-effect models if heterogeneity was present, otherwise a fixed-effect model was applied.

RESULTS

A total of twenty-one studies were included with 29,000 participants. Of them, mean age and percent male were 48.1 years and 45.1, respectively. The pooled USMD (95% CI) of SF-36 between PD and HD (base) were 1.86 (0.47, 3.24) and 0.42 (- 1.99, 2.82) for mental component and physical component summary scores, respectively. For EQ-5D, the pooled USMD of utility and visual analogue scale (VAS) score were 0.02 (- 0.06, 0.10) and 3.56 (1.73, 5.39), respectively. The pooled USMD of KDQOL were 9.67 (5.67, 13.68), 6.71 (- 5.92, 19.32) 6.30 (- 0.41, 12.18), 2.35 (- 4.35, 9.04), 2.10 (0.07, 4.13), and 1.21 (- 2.98, 5.40) for burden of kidney disease, work status, effects of kidney disease, quality of social interaction, symptoms, and cognitive function.

CONCLUSION

Patients with chronic kidney disease (CKD) stage 5 or ESRD treated with PD had better generic HRQoL measured by SF-36 and EQ-5D than HD patients. In addition, PD had higher specific HRQoL by KDQOL than HD patients in subdomain of physical functioning, role limitations due to emotional problems, effects and burden of kidney disease.

[Impact of renal replacement therapy on frail older adults]

INTRODUCTION

End-stage renal disease prevalence is increasing in older adults. Frailty is highly prevalent in older adults with end-stage renal disease. However, there are no prospective studies comparing the performance of the different modalities of renal replacement therapy (RRT) in frail older adults.

OBJECTIVE

To compare clinically relevant outcomes (hospital admission, falls, hip fractures, and mortality) in prefrail and frail older adults according to the modality of RRT: peritoneal dialysis or haemodialysis.

METHODS

A prospective observational study in prefrail and frail older adults (according to FRAIL scale) on peritoneal dialysis and haemodialysis was carried out. An evaluation was made using baseline characteristics (age, Charlson, body mass index, time on RRT, compliance with Kt/V dose, haemoglobin, and albumin). The patients were followed-up over 12 months, recording mortality, days and number of hospital admissions, falls, and hip fractures.

RESULTS

A total of 54/65 (83%) older adults on RRT met criteria for prefrailty or frailty, and signed informed consent (27 in each modality). Baseline characteristics were similar, except for serum albumin and time on RRT, both of which were significantly lower in the peritoneal dialysis group. The FRAIL score was similar in both groups. Baseline FRAIL correlated with higher comorbidity, lower albumin levels, and non-compliance of Kt/V dose, while it was independent of age, body mass index, and time on RRT. Days and number of hospital admissions at 12 months were similar in patients on peritoneal dialysis and haemodialysis. Survival on peritoneal dialysis and haemodialysis was similar. There were no differences in falls or hip fractures.

CONCLUSIONS

Pre-frail and frail older adults on peritoneal dialysis and haemodialysis have similar clinical outcomes.

Supporting and maintaining the frail patient on long-term renal replacement therapy

The number of frail patients reaching end-stage kidney disease is increasing. They have a high level of comorbidity and symptom burden which need to be considered when making management plans. For those who choose renal replacement therapy, it is important to establish goals and ceilings of care and to provide holistic care focusing on optimising quality of life. Advance care planning is the process of documenting the patient's preferences for their treatment in the event they lose capacity to make decisions about their treatment.

Peritoneal Dialysis in Elderly Patients: Clinical Experience

Many older patients do not cope well with hemodialysis, yet the proportion of older patients on peritoneal dialysis (PD) is considerably lower than for younger patients. This is despite the fact that clinical outcome studies show that older patients cope as well as, if not better than, younger patients on PD. Furthermore, the North Thames Dialysis Study, a prospective study of patients ≥70 years old, has shown that survival, hospitalization, and quality of life were identical for patients on hemodialysis and patients on PD.

Impact of First Dialysis Modality on Outcome of Patients Contraindicated for Kidney Transplant

Background

We compared, in patients contraindicated for kidney transplant, outcomes between those patients who were only on hemodialysis (HD) and those who were given peritoneal dialysis (PD) as first renal replacement therapy (RRT).

Design

Prospective, population-based cohort study of incident cases of end-stage renal disease between June 1997 and June 1999.

Setting

A network of dialysis care: NEPHROLOR, that is, all the renal units in Lorraine, one of the 22 French administrative regions (population over 2.3 million people).

Participants

387 patients were contraindicated for kidney transplant during the first 2 years of RRT: 284 were on HD, 103 on PD. Mean age was 67.6 ± 11.3 years for HD patients and 70.8 ± 11.4 years for PD patients ( p = 0.015).

Main Outcome Measures

Mortality until June 2003, hospitalization over the 2 first years of RRT, and Kidney Disease and Quality of Life Short Form (KDQOL-SF) 6 and 12 months after initiation of RRT.

Results

HD patients were more likely to die from cardiac or cerebrovascular causes, PD from cachexia or withdrawal from dialysis. Whatever mode of RRT, the unadjusted 2-year and 5-year survival rates were similar ( p = 0.98). The rate of total duration of hospital stay per month of RRT was similar in HD and PD groups: 2.7 ± 4.5 and 2.9 ± 4.2 days respectively ( p = 0.7). PD was associated with better quality of life than HD. The dimensions Role limitation due to emotional function, Burden of kidney disease, and Role limitation due to physical function ranked first, second, and third for PD.

Conclusion

In Lorraine, end-stage renal disease patients who were given PD as first-line RRT had no excess of death risk or hospitalizations, and better quality of life the first year of RRT.

Should Older Patients be Offered Peritoneal Dialysis?

On haemodialysis, my life was not my own — handing control to nursing staff for 4 hours, 3 days a week, surrounded by noisy machines and unhappy patients, returning home after 11 hours, too exhausted to eat and falling into bed. However, peritoneal dialysis has given me back my life. I am in control of me and am treated like a human being, not just a patient. There are minor drawbacks, such as storage for the fluids and being unable to have a bath, but it is a small price to pay.

Analysis of risk factors and outcome in peritoneal dialysis patients with early-onset peritonitis: a multicentre, retrospective cohort study

OBJECTIVES

To investigate the risk factors associated with early-onset peritonitis (EOP) and their influence on patients' technique survival and mortality.

STUDY DESIGN

Retrospective, cohort study.

SETTING

Three peritoneal dialysis (PD) units in Shanghai.

PARTICIPANTS

PD patients from 1 June 2006 to 1 May 2018 were recruited and followed up until 31 December 2018. According to time-to-first episode of peritonitis, patients were divided into non-peritonitis (n=144), EOP (≤6 months, n=74) and late-onset peritonitis (LOP) (>6 months, n=139).

PRIMARY AND SECONDARY OUTCOME MEASURES

EOP was defined as the first episode of peritonitis occurring within 6 months after the initiation of PD. The outcomes were all-cause mortality and technique failure.

RESULTS

Of the 357 patients, 74 (20.7%) patients developed their first episode of peritonitis within the first 6 months. Compared with the LOP group, the EOP group had older ages, more female patients, higher Charlson Comorbidity Index (CCI) score, lower serum albumin levels and renal function at the time of initiation of PD, and higher diabetes mellitus and peritonitis rates (p<0.05). Staphylococcus was the most common Gram-positive organism in both EOP and LOP groups. The multivariate logistic regression analysis showed that factors associated with EOP included a higher CCI score (OR 1.285, p=0.011), lower serum albumin level (OR 0.924, p=0.016) and lower Kt/V (OR 0.600, p=0.018) at start of PD. In the Cox proportional-hazards model, EOP was more likely a predictor of technique failure (HR 1.801, p=0.051). There was no difference between EOP and LOP for all-cause mortality.

CONCLUSION

A higher CCI score and lower serum albumin level and Kt/V at PD initiation were significantly associated with EOP. EOP also predicted a high peritonitis rate and poor clinical outcome.

Hemodialysis vascular access in the elderly-getting it right

Choosing the optimal hemodialysis vascular access for the elderly patient is best achieved by a patient-centered coordinated multidisciplinary team approach that aligns the patient's end-stage kidney disease Life-Plan, i.e., the individual treatment approach (supportive care, time-limited or long-term kidney replacement therapy, or combination thereof) and selection of dialysis modality (peritoneal dialysis versus hemodialysis) with the most suitable dialysis access. Finding the right balance between the patient's preferences, the likelihood of access function and survival, and potential complications in the context of available resources and limited patient survival can be extremely challenging. The framework for choosing the most appropriate vascular access for the elderly presented in this review considers the individual end-stage kidney disease Life-Plan, the patient life expectancy, the likelihood of access function and survival, the timing of dialysis relative to access placement, prior access history, and patient preference. This complex decision-making process should be dynamic in order to accommodate patients' changing needs and life and health circumstances. Effective and timely communication between the patient, their caregivers, and treating team is key to delivering truly patient-centered care. Delivering this care also requires overcoming the limitations of the currently available evidence that is predominantly based on observational data with its inherent risks of bias. While challenging, future randomized controlled studies exploring the risks, benefits, costs, and timing of placement of available access types in the elderly are required to help us "get it right" for our patients.

Health related quality of life of dialysis patients in Malaysia: Haemodialysis versus continuous ambulatory peritoneal dialysis

BACKGROUND

Health related quality of life (HRQOL) is an important predictor of clinical outcomes for End Stage Renal Disease (ESRD) patients and to establish quality adjusted life years (QALYs) for economic evaluation studies. This study aims to measure the health utilities and to identify socio-demographic and clinical factors associated with HRQOL for haemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD) in Malaysia.

METHODS

A total of 141 patients (77 HD and 64 CAPD) from 1 federal and four state hospitals participated in this cross-sectional study. Patients were randomly selected from the National Renal Registry (NRR) using a stratified random sampling. The EQ-5D-3 L questionnaire was used to measure HRQOL. Variables investigated include dialysis modalities, sociodemographic characteristics, co-morbidities and biochemical markers. Utilities are measured on an ordinal scale of 0-1, where 1 indicates full health and 0 indicates death.

RESULTS

The mean utility scores were 0.854 ± 0.181 and 0.905 ± 0.124 (p > 0.05) and the mean Visual Analogue Scale (VAS) scores were 76.2 ± 12.90 and 77.1 ± 10.26 (p > 0.05) for HD and CAPD patients respectively. There was a significant difference in problems reported between HD (35.1%) and CAPD (15.6%) on usual activities dimension (p = 0.009). The proportion of patients having problems in the pain/discomfort domain in both modalities was high (34.0%). Haemoglobin (< 10 g/dL) (p = 0.003), number of co-morbidities ≥3 (p = 0.004) and wheelchair-bound status (p < 0.001) were significant predictors of poor HRQOL.

CONCLUSIONS

The present cross-sectional study shows that CAPD patients have a higher utility index score than HD patients but this was not statistically significant. The utilities index score may be used to calculate QALYs.

Health-related quality of life as predictor of mortality in end-stage renal disease patients: an observational study

Background

Health-related quality of life (HRQoL) is an important component of patient-centered outcomes and a useful parameter for monitoring quality of care. We assessed HRQoL, its determinants, and associations with mortality in patients with end-stage renal disease (ESRD).

Methods

Short Form-36 was used to assess HRQoL, its domain components, and physical (PCS) and mental (MCS) composite summary scores in altogether 400 (338 incident and 62 prevalent) dialysis patients with median age 64 years, 37% women, 24% diabetes mellitus (DM), 49% cardiovascular disease (CVD), and median estimated glomerular filtration rate (eGFR) of 5.3 (3.0–9.4) ml/min/1.73². Results were analyzed separately for 338 incident patients starting on hemodialysis (HD; 68%) or peritoneal dialysis (PD; 32%), and 62 prevalent PD patients. Mortality risk was analyzed during up to 60 months (median 28 months).

Results

Linear multivariate regression analysis showed that in incident dialysis patients, 1-SD higher PCS associated negatively with 1-SD higher age, DM and CVD, and positively with 1-SD higher hemoglobin and sodium (adjusted r² = 0.17). In 62 prevalent PD patients, 1-SD higher PCS was negatively associated with 1-SD higher age. MCS was not associated to any of the investigated factors. Multivariate Cox regression analysis showed that in incident dialysis patients, 1-SD increase of PCS associated with lower all-cause mortality, hazard ratio 0.65 (95% confidence interval 0.52–0.81), after adjustments for age, sex, DM, CVD, plasma albumin, C-reactive protein and eGFR whereas 1-SD lower MCS did not associate with mortality. In PD patients, neither PCS nor MCS associated with mortality.

Conclusions

MCS did not associate with any of the investigated clinical factors, whereas lower PCS associated with higher age, CVD, DM, and lower hemoglobin and sodium levels. MCS was not associated with mortality, whereas lower PCS associated with increased mortality risk. These results suggest that HRQoL - in addition to its role as patient-centered outcome - matters also for hard clinical outcomes in ESRD patients. Our knowledge about factors influencing MCS in ESRD patients is limited and should motivate further studies.

Electronic supplementary material

The online version of this article (10.1186/s12882-019-1318-x) contains supplementary material, which is available to authorized users.

Longitudinal Trends in Quality of Life and Physical Function in Frail Older Dialysis Patients: A Comparison of Assisted Peritoneal Dialysis and In-Center Hemodialysis

Background

In-center hemodialysis (HD) has been the standard treatment for older dialysis patients, but reports suggest an associated decline in physical and cognitive function. Cross-sectional data suggest that assisted peritoneal dialysis (aPD), an alternative treatment, is associated with quality of life (QoL) outcomes that are comparable to in-center HD. We compared longitudinal changes in QoL between modalities.

Methods

We enrolled 106 aPD patients, matched with 100 HD patients from 20 renal centers in England and Northern Ireland. Patients were assessed quarterly for 2 years using the Hospital Anxiety and Depression Scale (HADS), SF-12 physical and mental scores, symptom score, Illness Intrusiveness Rating Scale (IIRS), Barthel's score, and the Renal Treatment Satisfaction Questionnaire (RTSQ). Mixed model analysis was used to assess the impact of dialysis modality on these outcomes during follow-up. P values were adjusted for multiple significance testing.

Results

Multivariate analysis showed no difference in any of the outcome measures between aPD and HD. Longitudinal trends in outcomes were also not significantly different. Higher age at baseline was associated with lower IIRS and RTSQ scores during follow-up. One-hundred and twenty-five (60.6%) patients dropped out of the study: 59 (28.6%) died, 61 (29.6%) withdrew during follow-up, and 5 (2.5%) were transplanted.

Conclusions

Quality of life outcomes in frail older aPD patients were equivalent to those receiving in-center HD. Assisted PD is thus a valid alternative to HD for older people with end-stage kidney disease (ESKD) wishing to dialyze at home.

The Association of Functional Status with Mortality and Dialysis Modality Change: Results from the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS)

BACKGROUND

Little is known about the prevalence of functional impairment in peritoneal dialysis (PD) patients, its variation by country, and its association with mortality or transfer to hemodialysis.

METHODS

A prospective cohort study was conducted in PD patients from 7 countries in the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) (2014 - 2017). Functional status (FS) was assessed by combining self-reports of 8 instrumental and 5 basic activities of daily living, using the Lawton-Brody and the Katz questionnaires. Summary FS scores, ranging from 1.25 (most dependent) to 13 (independent), were based on the patient's ability to perform each activity with or without assistance. Logistic regression was used to estimate the odds ratio (OR; 95% confidence interval [CI]) of a FS score < 11 comparing each country with the United States (US). Cox regression was used to estimate the hazard ratio (HR; 95% CI) for the effect of a low FS score on mortality and transfer to hemodialysis, adjusting for case mix.

RESULTS

Of 2,593 patients with complete data on FS, 48% were fully independent (FS = 13), 32% had a FS score 11 to < 13, 14% had a FS score 8 to < 11, and 6% had a FS score < 8. Relative to the US, low FS scores (< 11; more dependent) were more frequent in Thailand (OR = 10.48, 5.90 - 18.60) and the United Kingdom (UK) (OR = 3.29, 1.77 - 6.08), but similar in other PDOPPS countries. The FS score was inversely and monotonically associated with mortality but not with transfer to hemodialysis; the HR, comparing a FS score < 8 vs 13, was 4.01 (2.44 - 6.61) for mortality and 0.91 (0.58 - 1.43) for transfer to hemodialysis.

CONCLUSION

Regional differences in FS scores observed across PDOPPS countries may have been partly due to differences in regional patient selection for PD. Functional impairment was associated with mortality but not with permanent transfer to hemodialysis.

Longitudinal patterns of health-related quality of life and dialysis modality: a national cohort study

Background

Health-related quality of life (HrQoL) varies among dialysis patients. However, little is known about the association of dialysis modality with HrQoL over time. We describe longitudinal patterns of HrQoL among chronic dialysis patients by treatment modality.

Methods

National retrospective cohort study of adult patients who initiated in-center dialysis or a home modality (peritoneal or home hemodialysis) between 1/2013 and 6/2015. Patients remained on the same modality for the first 120 days of the first two years. HrQoL was assessed by the Kidney Disease and Quality of Life-36 (KDQOL) survey in the first 120 days of the first two years after dialysis initiation. Home modality patients were matched to in-center patients in a 1:5 fashion.

Results

In-center (n=4234) and home modality (n=880) patients had similar demographic and clinical characteristics. In-center dialysis patients had lower mean KDQOL scores across several domains compared to home modality patients. For patients who remained on the same modality, there was no change in HrQoL. However, there were trends towards clinically meaningful changes in several aspects of HrQoL for patients who switched modalities. Specifically, physical functioning decreased for patients who switched from home to in-center dialysis (p< 0.05).

Conclusions

Among a national cohort of chronic dialysis patients, there was a trend towards different patterns of HrQoL life that were only observed among patients who changed modality. Patients who switched from home to in-center modalities had significant lower physical functioning over time. Providers and patients should be mindful of HrQoL changes that may occur with dialysis modality change.

Electronic supplementary material

The online version of this article (10.1186/s12882-018-1198-5) contains supplementary material, which is available to authorized users.

Peritoneal dialysis in older adults: Evaluation of clinical, nutritional, metabolic outcomes, and quality of life

The number of older adults requiring dialysis is increasing worldwide, whereas the use of peritoneal dialysis (PD) in this population is lower with respect to younger patients, despite the theoretical advantages of PD respect to hemodialysis. This is most likely due to the concern that older patients may not be able to correctly and safely manage PD.We aimed to prospectively compare clinical, nutritional and metabolic outcomes and measures of quality of life between younger (<65 years old) and older (≥65 years old) patients on PD.PD patients were enrolled and divided into 2 groups according to age (Group A < 65 years, Group B ≥ 65 years). Clinical and instrumental parameters, and quality of life were evaluated at baseline (start of PD) (T0) and at 24 months (T1). Technique survival, mortality, total number of hospitalizations, and the index of peritonitis (episodes of peritonitis/month) were also evaluated.Fifty-one patients starting PD were enrolled. Group A included 22 patients (48.7 ± 8.3 years), and Group B consisted of 29 patients (74.1 ± 6.4 years). At baseline, the 2 groups showed no differences in cognitive status, whereas Group A showed higher total cholesterol (P = .03), LDL (P = .03), and triglycerides (P = .03) levels and lower body mass index (P = .02) and carotid intima media thickness (P < .0001) with respect to Group B. At T1 Group B showed, compared to baseline, a significant reduction in albumin (P < .0001) and phosphorus (P = .045) levels, while no significant differences on body composition, technique survival, total number of hospitalizations, index of peritonitis, and quality of life indices were observed.Our data do not show clinically relevant barriers to use PD in older adult patients, supporting its use in this population. Nutritional and metabolic parameters should be carefully monitored in older PD patients.

The Health-Related Quality of Life of Chinese Patients on Hemodialysis and Peritoneal Dialysis

AIMS

Our aim was to compare health-related quality of life (HRQOL) between end-stage renal disease (ESRD) patients and the Hong Kong general population to identify how the mode of dialysis and other factors were associated with HRQOL.

METHODS

We conducted a cross-sectional study involving 253 hemodialysis (HD) patients and 103 peritoneal dialysis (PD) patients recruited in 2014-2015. Their HRQOL was evaluated using Kidney Disease and Quality of Life-36 (KDQOL-36) sub-scale scores and the Short Form-6 Dimensions (SF-6D) health preference score. One-way analysis of variance was used to analyze the difference in mean KDQOL-36 and SF-6D scores among PD patients, HD patients, and an exact age- and sex-matched general population. Multiple linear regressions were conducted to evaluate factors associated with the KDQOL-36 and SF-6D scores.

RESULTS

The physical HRQOL of ESRD patients on dialysis was worse than that of the age- and sex-matched general population (38.4 vs. 49.6), but mental HRQOL was similar (50.7 vs. 52.0). After adjusting for all baseline characteristics, male subjects was associated with higher physical component summary (PCS), SF-6D, and symptom scores. A higher level of education (secondary or tertiary) was associated with higher mental component summary (MCS), SF-6D, symptom, and effects scores. Patients who were female, younger, married, and less educated and had a history of cardiovascular disease (CVD) and did not achieve target hemoglobin and albumin levels were associated with poorer HRQOL outcomes.

CONCLUSIONS

HD was associated with a greater negative impact of ESRD on daily lives than was PD, which may be a consideration when deciding on the dialysis modality for first-line renal replacement therapy. To improve HRQOL among patients on maintenance dialysis, more attention should be paid to those with demographic risk factors, preventing CVD, and meeting clinical dialysis outcome targets such as hemoglobin and albumin levels.

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.

PD vs HD in Post-Economic Crisis Greece-Differences in Patient Characteristics and Estimation of Therapy Cost

OBJECTIVE

The aim of this study was to investigate patient characteristics and make an estimation of the cost of peritoneal dialysis (PD) and hemodialysis (HD) to Greek society during the economic crisis.

METHODS

We recorded the characteristics and the total cost of dialysis treatment in 100 patients on PD and 100 on HD. Total costs included dialysis procedure, consumables, drugs, laboratory tests, food, and transportation fees (only HD), covered by patients' insurance. Also included were medical and administrative salaries, purchase and maintenance of equipment and sanitary material, all covered by the state hospital.

RESULTS

The mean patient age was 64.5 ± 16.8 years (PD) and 62.8 ± 15.1 (HD) (p < 0,001). The most common cause of end-stage renal disease (ESRD) was diabetes (32% for PD and 24% for HD patients). A total of 35% of the PD patients were employed vs 4% of the HD patients (p < 0,001). The mean distance from home for PD patients was 41.6 ± 17.3 km, while for HD patients, it was 9.4 ± 1.5 km (p < 0,001). Mean monthly cost for PD and HD treatment per patient was €4,019.20 ± 1,126.30 and €3,254.30 ± 37.50, respectively, both fully covered by patients' insurance. Mean monthly cost for PD or HD dialysis unit maintenance was €11,660.80 and €56,270.50, respectively, also fully covered by the state.

CONCLUSION

There is likely to be a considerable difference in terms of total cost of PD vs HD therapy, owing to the fact that the operational cost of a PD unit appears to be significantly lower than that of a HD unit.

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.

Introduction of Renal Key Performance Indicators Associated with Increased Uptake of Peritoneal Dialysis in a Publicly Funded Health Service

♦ BACKGROUND: Increased demand for treatment of end-stage kidney disease has largely been accommodated by a costly increase in satellite hemodialysis (SHD) in most jurisdictions. In the Australian State of Victoria, a marked regional variation in the uptake of home-based dialysis suggests that use of home therapies could be increased as an alternative to SHD. An earlier strategy based solely on increased remuneration had failed to increase uptake of home therapies. Therefore, the public dialysis funder adopted the incidence and prevalence of home-based dialysis therapies as a key performance indicator (KPI) for its health services to encourage greater uptake of home therapies. ♦ METHODS: A KPI data collection and bench-marking program was established in 2012 by the Victorian Department of Health and Human Services, with data provided monthly by all renal units in Victoria using a purpose-designed website portal. A KPI Working Group was responsible for analyzing data each quarter and ensuring indicators remained accurate and relevant and each KPI had clear definitions and targets. We present a prospective, observational study of all dialysis patients in Victoria over a 4-year period following the introduction of the renal KPI program, with descriptive analyses to evaluate the proportion of patients using home therapies as well as home dialysis modality survival. ♦ RESULTS: Following the introduction of the KPI program, the net growth of dialysis patient numbers in Victoria remained stable over 4 years, at 75 - 80 per year (approximately 4%). However, unlike the previous decade, about 40% of this growth was through an increase in home dialysis, which was almost exclusively peritoneal dialysis (PD). The increase was identified particularly in the young (20 - 49) and the elderly (> 80). Disappointingly, however, 67% of these incident patients ceased PD within 2 years of commencement, 46% of whom transferred to SHD. ♦ CONCLUSIONS: Introduction of a KPI program was associated with an increased uptake of PD but not home HD. This change in clinical practice restricted growth of SHD and reduced pressure on satellite services. The effect was offset by a modest PD technique survival. Many patients in whom PD was unsuccessful were subsequently transferred to SHD rather than home HD.

Survival of Elderly Adults Undergoing Incident Home Hemodialysis and Kidney Transplantation

OBJECTIVES

To compare the mortality of elderly adults with end-stage renal disease (ESRD) treated with home hemodialysis (HD) with that of those receiving a kidney transplant (KTx).

DESIGN

Prospective cohort.

SETTING

Pertinent data for the two groups were obtained from electronic medical records from a large dialysis provider and the U.S. Renal Data System.

PARTICIPANTS

Using data from elderly adults (aged ≥65) who started home HD and underwent KTx in the US between 2007 and 2011, a 1:1 propensity score (PS)-matched cohort of 960 elderly adults was created, and the association between treatment modality and all-cause mortality was examined using Cox proportional hazards and competing risk regression survival models using modality failure as a competing event.

MEASUREMENTS

Modality of renal replacement therapy.

RESULTS

The baseline mean age ± standard deviation of the PS-matched individuals undergoing home HD was 71 ± 6, and that of KTx recipients was 71 ± 5, 69% of both groups were male, 81% of those undergoing home HD and 79% of KTx recipients were white, and 11% and 12%, respectively, were African American. Median follow-up time was 205 days (interquartile range (IQR) 78-364 days) for those undergoing home HD and 795 days (IQR 366-1,221 days) for KTx recipients. There were 97 deaths (20%, 253/1,000 patient-years, 95% confidence interval (CI) = 207-309/1,000 patient-years) in the home HD group and 48 deaths (10%, 45/1,000 patient-years, 95% CI = 34-60/1,000 patient-years) in the KTx group. Elderly adults undergoing home HD had a risk of mortality that was almost five times as high as that of KTx recipients (hazard ratio = 4.74, 95% CI = 3.25-6.91). Similar results were seen in competing risk regression analyses (subhazard ratio = 4.71, 95% CI = 3.27-6.79). Results were consistent across different types of kidney donors and subgroups divided according to various recipient characteristics.

CONCLUSION

Elderly adults with ESRD who receive a KTx have greater survival than those who undergo home HD. Further studies are needed to assess whether KTx receipt is associated with other benefits such as better quality of life and lower hospitalization rates.

The influence of different dialysis modalities on the quality of life of patients with end-stage renal disease: A systematic literature review

OBJECTIVES

This study aims to generate evidence regarding the relationships of different dialysis modalities with HR-QOL.

DESIGN

A systematic review was conducted to investigate the HR-QOL of patients treated with different dialysis modalities.

METHODS

A literature search was conducted for English language articles in the CINAHL, Medline and PubMed databases published from January 1990 through May 2016. Specifically, we sought articles that would compare the HR-QOL of hemodialysis (HD) and peritoneal dialysis (PD) patients in terms of physiological, psychological and social functioning, as well as disease symptoms. Thirty-four articles met the study inclusion criteria and were included into the analysis.

RESULTS

The research results indicated no significant differences in HR-QOL between HD and PD treatment. However, a higher percentage of patients who received PD had a better HR-QOL in terms of physiological, psychological, social and disease symptoms.

CONCLUSIONS

Despite the fact that the results of this study showed no difference in HR-QOL between HD and PD treatment, its review of relevant references can serve as a reference for health professionals. However, patients' conditions must still be taken into account when making suggestions about which dialysis modality a patient should use.

Measuring health-related quality of life in patients with conservatively managed stage 5 chronic kidney disease: limitations of the Medical Outcomes Study Short Form 36: SF-36

PURPOSE

Chronic kidney disease (CKD) negatively affects health-related quality of life (HRQoL), which is often measured using the Medical Outcomes Study Short Form 36 (SF-36) questionnaire. However, the adequacy of SF-36 in this population has not been reported. We aimed to determine floor and ceiling effects and responsiveness to change of SF-36 in patients with conservatively managed stage 5 CKD.

METHODS

SF-36 data were collected prospectively. Floor and ceiling effects were estimated for each SF-36 scale and summary measure based on raw scores. The minimal clinically important difference (MCID) was estimated using a combination of anchor-based and distribution-based methods. Responsiveness to change was assessed by comparing MCID for each scale and summary measure to its smallest detectable change.

RESULTS

SF-36 data were available for 73 of the 74 study participants. Using baseline data, floor and/or ceiling effects were detected for 3 of the 8 SF-36 scales. The anchor-based estimation of MCID based on differences in baseline functional status yielded the most reliable results. For the physical component summary, MCID was estimated at 5.7 points. Whilst the two SF-36 summary measures were responsive to change and free of floor and/or ceiling effects, six of the eight scales were not.

CONCLUSIONS

This small study of patients with conservatively managed stage 5 CKD found that only the summary measures of SF-36 and 2 of its 8 scales can be used to assess changes in HRQoL over time. These findings suggest that in this population, alternative HRQoL assessment tools should be considered for future studies.

Cost-effectiveness of hemodialysis and peritoneal dialysis: A national cohort study with 14 years follow-up and matched for comorbidities and propensity score

Although treatment for the dialysis population is resource intensive, a cost-effectiveness analysis comparing hemodialysis (HD) and peritoneal dialysis (PD) by matched pairs is still lacking. After matching for clinical characteristics and propensity scores, we identified 4,285 pairs of incident HD and PD patients from a Taiwanese national cohort during 1998-2010. Survival and healthcare expenditure were calculated by data of 14-year follow-up and subsequently extrapolated to lifetime estimates under the assumption of constant excess hazard. We performed a cross-sectional EQ-5D survey on 179 matched pairs of prevalent HD and PD patients of varying dialysis vintages from 12 dialysis units. The product of survival probability and the mean utility value at each time point (dialysis vintage) were summed up throughout lifetime to obtain the quality-adjusted life expectancy (QALE). The results revealed the estimated life expectancy between HD and PD were nearly equal (19.11 versus 19.08 years). The QALE's were also similar, whereas average lifetime healthcare costs were higher in HD than PD (237,795 versus 204,442 USD) and the cost-effectiveness ratios for PD and HD were 13,681 and 16,643 USD per quality-adjusted life year, respectively. In conclusion, PD is more cost-effective than HD, of which the major determinants were the costs for the dialysis modality and its associated complications.

Change in quality of life and one-year mortality risk in maintenance dialysis patients

BACKGROUND

Quality of life (QOL) is an important metric of high-quality dialysis care. QOL is commonly measured by the Short Form 36 Questionnaire (SF-36), which provides two summary scores: a mental component score (MCS) and a physical component score (PCS). Poor QOL is associated with mortality in dialysis patients. Small studies show that changes in QOL also predicts mortality. We investigated whether changes in QOL over time are associated with mortality in a large cohort of maintenance hemodialysis patients.

METHODS

This retrospective study was conducted in 1017 outpatient dialysis facilities. Over 10,000 hemodialysis patients completed two SF-36 surveys. We compared 1-year morality rates in those whose MCS or PCS increased or decreased ±5 vs. those whose did not.

RESULTS

For those who completed two surveys, mean score for PCS was unchanged, whereas MCS increased slightly (48.6 vs. 48.9, p = 0.05). Individual patients, however, showed marked variation. On the second survey, more than half of patients demonstrated a ± 5 point change in the PCS and/or MCS. After multivariate adjustment, a ≥ 5 decrease in MCS was associated with an increase in mortality (HR = 1.33, 95 % CI 1.18, 1.50).

CONCLUSIONS

Clinicians should be aware that many patients experience a significant change in both the MCS and PCS on dialysis. A MCS decrease of ≥5 was associated with increased mortality. More study is needed to determine whether this is a causal relationship. Physicians should evaluate root causes and seek to mitigate declines in QOL whenever possible.

Quality of Life and Physical Function in Older Patients on Dialysis: A Comparison of Assisted Peritoneal Dialysis with Hemodialysis

BACKGROUND AND OBJECTIVES

In-center hemodialysis (HD) is often the default dialysis modality for older patients. Few centers use assisted peritoneal dialysis (PD), which enables treatment at home. This observational study compared quality of life (QoL) and physical function between older patients on assisted PD and HD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Patients on assisted PD who were >60 years old and on dialysis for >3 months were recruited and matched to patients on HD (needing hospital transport) by age, sex, diabetes, dialysis vintage, ethnicity, and index of deprivation. Frailty was assessed using the Clinical Frailty Scale. QoL assessments included Hospital Anxiety and Depression Scale (HADS), Short Form-12, Palliative Outcomes Symptom Scale (renal), Illness Intrusiveness Rating Scale, and Renal Treatment Satisfaction Questionnaire (RTSQ). Physical function was evaluated by Barthel Score and timed up and go test.

RESULTS

In total, 251 patients (129 PD and 122 HD) were recruited. In unadjusted analysis, patients on assisted PD had a higher prevalence of possible depression (HADS>8; PD=38.8%; HD=23.8%; P=0.05) and higher HADS depression score (median: PD=6; HD=5; P=0.05) but higher RTSQ scores (median: PD=55; HD=51; P<0.01). In a generalized linear regression model adjusting for age, sex, comorbidity, dialysis vintage, and frailty, assisted PD continued to be associated with higher RTSQ scores (P=0.04) but not with other QoL measures.

CONCLUSIONS

There are no differences in measures of QoL and physical function between older patients on assisted PD and comparable patients on HD, except for treatment satisfaction, which is higher in patients on PD. Assisted PD should be considered as an alternative to HD for older patients, allowing them to make their preferred choices.

Elderly Peritoneal Dialysis Compared with Elderly Hemodialysis Patients and Younger Peritoneal Dialysis Patients: Competing Risk Analysis of a Korean Prospective Cohort Study

The outcomes of peritoneal dialysis (PD) in elderly patients have not been thoroughly investigated. We aimed to investigate the clinical outcomes and risk factors associated with PD in elderly patients. We conducted a prospective observational nationwide adult end-stage renal disease (ESRD) cohort study in Korea from August 2008 to March 2013. Among incident patients (n = 830), patient and technical survival rate, quality of life, and Beck’s Depression Inventory (BDI) scores of elderly PD patients (≥65 years, n = 95) were compared with those of PD patients aged ≤49 years (n = 205) and 50~64 years (n = 192); and elderly hemodialysis (HD) patients (n = 315). The patient death and technical failure were analyzed by cumulative incidence function. Competing risk regressions were used to assess the risk factors for survival. The patient survival rate of elderly PD patients was inferior to that of younger PD patients (P<0.001). However, the technical survival rate was similar (P = 0.097). Compared with elderly HD patients, the patient survival rate did not differ according to dialysis modality (P = 0.987). Elderly PD patients showed significant improvement in the BDI scores, as compared with the PD patients aged ≤49 years (P = 0.003). Low albumin, diabetes and low residual renal function were significant risk factors for the PD patient survival; and peritonitis was a significant risk factor for technical survival. Furthermore, low albumin and hospitalization were significant risk factors of patient survival among the elderly. The overall outcomes were similar between elderly PD and HD patients. PD showed the benefit in BDI and quality of life in the elderly. Additionally, the technical survival rate of elderly PD patients was similar to that of younger PD patients. Taken together, PD may be a comparable modality for elderly ESRD patients.

The Overuse, Underuse, and Misuse of Dialysis in ESKD Patients with Dementia

The profile of patients on chronic dialysis has shifted. There is a growing group of older patients with comorbid dementia and ESKD, who are at risk of overuse, underuse, and misuse of dialysis. Policy is lacking to help guide treatment decisions in this group. This paper explores clinical considerations specific to patients with comorbid ESKD and dementia. These include: the impact of comorbid dementia on dialysis effectiveness and feasibility; burden of care issues that are specific to patients with dementia; and capacity, autonomy, and consent. A better understanding of these issues may help guide discussions and decision making about treatment. For some older patients with multiple comorbidities including dementia, dialysis does not provide survival or quality of life benefit compared to medical management. These patients also experience additional treatment burden due to a 'dementia unfriendly' environment. However, exceptions may include patients who are younger, more independent, and have fewer comorbidities. Patients with dementia are often inappropriately assumed to lack capacity to participate in treatment decision making, and are at risk of having their preferences overlooked. Many patients with mild-to-moderate dementia remain capable of reporting their preferences and quality of life, and should always be involved in treatment discussions where possible.

Quality of life and stressors in patients with chronic kidney disease depending on treatment

This study evaluated health-related quality of life (HRQOL) in a Spanish sample of chronic kidney disease patients (n = 90) undergoing different renal replacement therapies, considering the influence of treatment stressors, mood, anxiety and quality of sleep. While all patients had worse physical functioning than controls (p < .01), only those undergoing haemodialysis (HD) showed worse physical well-being, occupational functioning, spiritual fulfillment and more health interference with work (p < .05). They also obtained higher depression scores than renal transplant patients (TX) (p = .005). Those TX receiving the immunosuppressor sirolimus exhibited more cardiac/renal, cognitive and physical limitations than the rest (p < .05). Dialysis vintage correlated positively with sleep disturbances and depression scores and negatively with total Quality of Life (QLI) (p < .05). HD patients experienced more psychological distress than peritoneal dialysis patients (PD) (p = .036). Regression models including sleep, anxiety and depression were estimated for subscales of HRQOL. In TX patients, low depressive scores related to an optimal QLI in almost all subscales, while in HD patients they explained part of the variability in psychological well-being, interpersonal functioning and personal fulfillment. HD condition results in a QLI more distant to the standards of controls.