Outcomes of elderly peritoneal dialysis patients: 65-74 years old versus ≥ 75 years old

OBJECTIVE

To analyze the clinical data of elderly patients with peritoneal dialysis (PD) and compare patient and technique survival rates between Group 1 (65-74 years old) and Group 2 (≥75 years old).

METHODS

This retrospective study enrolled 296 elderly patients (≥65 years old) on maintenance PD who were admitted to the Peritoneal Dialysis Center of the Second Hospital of Soochow University. The patients were categorized by outcome into ongoing PD, changed to hemodialysis, renal recovery dialysis stopped, or death groups. The patients were divided into Group 1 (65-74 years old) and Group 2 (≥75 years old). Patient survival and technique survival rates were calculated by the Kaplan-Meier method. Factors associated with patient survival were analyzed using the Cox regression model.

RESULTS

There were 176 (59.5%) subjects in Group 1 and 120 (40.5%) subjects in Group 2. The primary causes of death were cardiovascular events, peritonitis, and other infections. The patient survival rates at 1, 3, and 5 years were 91.2%, 68.0%, and 51.3% in Group 1 and 76.8%, 37.5%, and 17.6% in Group 2 (p < 0.001, HR 0.387, 95% CI 0.282-0.530). There was no statistically significant difference in the technique survival rate between the two groups (p = 0.54).

CONCLUSION

The elderly PD patients in this cohort mostly died from cardiovascular events, with a higher patient survival rate in Group 1 and similar technique survival in both groups. Older age, lower prealbumin, higher creatinine, not being on activated vitamin D, and high Charlson's comorbidity index (CCI) score were independent risk factors for death.

Low-site versus traditional peritoneal dialysis catheterization: A meta-analysis

BACKGROUND

The objective of this study was to compare the complications of low-site peritoneal dialysis (PD) catheter placement and traditional open surgery in peritoneal dialysis catheter insertion.

METHODS

The following databases were searched from inception to September 6, 2019: PubMed, Embase, the Cochrane Library, China National Knowledge Infrastructure, and Wanfang. Eligible studies comparing low-site PD catheter placement and traditional open surgery in peritoneal dialysis catheter insertion were included. The data were analyzed using Review Manager Version 5.3.

RESULTS

Seven studies were included in the meta-analysis. A total of 504 patients were included in the low-site PD catheter placement group, and 325 patients were included in the traditional open surgery group. Compared with traditional open surgery, low-site PD catheter placement had a lower incidence rate of catheter displacement (odds ratios [OR] 0.11, 95% CI 0.05-0.22, P < .01) and noncatheter displacement dysfunction (OR 0.11, 95% CI 0.04-0.31, P < .01). However, there was no difference between the 2 catheter insertion methods concerning bleeding (OR 0.53, 95% CI 0.23-1.22, P = .13), PD fluid leakage (OR 0.40, 95% CI 0.15-1.10, P = .07), hypogastralgia (OR 0.95, 95% CI 0.32-2.80, P = .93), peritonitis (OR 0.70, 95% CI 0.32-1.54, P = .38), or exit-site and tunnel infections (OR 0.39, 95% CI 0.14-1.03, P = .06).

CONCLUSION

Low-site PD catheter placement reduced the risk of catheter displacement and noncatheter displacement dysfunction and did not increase the risk of bleeding, PD fluid leakage, hypogastralgia, peritonitis, or exit site and tunnel infections. Additional large multicenter randomized controlled trials are needed to confirm these conclusions.

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.

Does peritoneal dialysis have a role in urgent-start end-stage kidney disease?

Despite its many positive attributes, peritoneal dialysis remains underutilized, particularly in the United States. Urgent-start peritoneal dialysis (PD) has been proposed as a method of increasing PD prevalence. Urgent-start PD has been shown to be safe, feasible, and effective. However, urgent-start PD is also accompanied by several multidimensional challenges. This article is intended to equip the reader with a practical sense of whether an urgent-start PD program would be appropriate in his or her own clinical context and if appropriate, what factors would be necessary for such a program to flourish. As such, we summarize latent factors, which are necessary to consider before instituting an urgent-start PD. Then, using a series of clinical vignettes, highlight the component parts of a successful urgent-start PD program and the patient population who stand to benefit most from this strategy. The discussion is then balanced by presenting limitations to consider in the urgent-start PD approach.

Peritoneal dialysis catheter placement in the right lower quadrant is associated with a lower risk of catheter tip migration: a retrospective single-center study

PURPOSE

The aim of this study was to investigate the effect of a modified technique for peritoneal dialysis catheter placement in the right lower quadrant with respect to catheter tip migration.

METHODS

This retrospective study included 237 patients with end-stage renal disease who underwent implantation of a two-cuff straight-end swan-neck catheter for peritoneal dialysis. Ninety-eight patients received conventional catheter placement in the left quadrant (beside the umbilicus 12-13 cm above the pubic symphysis) with catheter exit site on the left, and 139 patients received modified catheter placement in the right lower quadrant (beside the umbilicus 6-7 cm above the pubic symphysis) with catheter exit site on the right. Dialysate inflow time, dialysate outflow time, ultrafiltration volume, infection, hemorrhage, intestinal obstruction, and catheter tip migration were recorded.

RESULTS

There were no significant differences in dialysate inflow time, dialysate outflow time, ultrafiltration volume, infection, hemorrhage, or intestinal obstruction between the conventional and modified groups. Catheter tip migration occurred in 19 (19.3%) of the 98 patients in the conventional group, and in 5 (3.6%) of the 139 patients in the modified group. The frequency of occurrence of catheter tip migration was significantly less in the modified group compared with the conventional group (p < 0.01). In addition, repositioning of the catheter occurred in all five patients with catheter tip migration in the modified group after conservative treatment, whereas 12 patients required surgical repositioning of the catheter in the conventional group.

CONCLUSIONS

The modified technique is superior to the conventional technique in reducing catheter tip migration. This technique can be widely performed in the clinic.

Clinical application of right low-position modified peritoneal dialysis catheterization

The aim of this study was to investigate peritoneal dialysis catheter malposition following low-position modified peritoneal dialysis catheterization and its clinical application value. A total of 48 patients receiving traditional peritoneal dialysis catheterization (the traditional group) and 95 patients receiving right low-position modified peritoneal dialysis catheterization (the modified group) from 2006 to 2011 were selected. The inflow time, outflow time, ultrafiltration volume of peritoneal dialysis solution and rate of peritoneal dialysis catheter malposition in the two groups of patients following surgery were compared and analyzed. There were no significant differences of inflow time, outflow time and ultrafiltration volume of the peritoneal dialysis solution between the two groups. In the modified group, no post-operative peritoneal dialysis catheter malposition occurred, therefore the incidence rate was 0. However, 9 patients in the traditional group presented peritoneal dialysis catheter malposition, an incidence rate of 18.75% (9/48). Among them, 6 patients required a second surgery. There was a statistically significant difference in the incidence rate of catheter malposition between the two groups (P<0.01). Right low-position modified peritoneal dialysis catheterization significantly reduced the incidence rate of peritoneal dialysis catheter malposition following peritoneal dialysis, and was shown to be significantly more effective than the traditional peritoneal dialysis catheterization and is therefore worth promoting for clinical use.

Peritoneal dialysis patient selection: characteristics for success

This review focuses on the strategy of patient selection for peritoneal dialysis (PD) based on published epidemiology studies and observational data. With the success of the PD first model in Hong Kong, experience shows that there is no particular patient group that cannot be put on PD except those who have major problems in the abdomen. Incident patients should be offered the choice to receive PD at the start of dialysis in order to preserve better the residual renal function. Concern has also been expressed for a time-dependent negative impact of PD on survival, although PD in general provides survival advantage at least during the first few years after the start of dialysis. Regular patient review is essential to allow prompt adjustment of the dialysis regimen and modality when required. Accumulating research suggests that center size has a significant effect on the patient and technique survival of patients undergoing PD. Comorbid diabetes, large and small body size, peritoneal membrane transport status, elderly age group, and socioeconomic status are important patient factors to consider. Good clinical and psychosocial care of the PD patients are essential as well as the attention to their compliance. Enhanced training to medical and nursing personnel on PD is one of the key success factors for improving its utilization and outcome.

Proteomic analysis of peritoneal dialysate fluid in patients with different types of peritoneal membranes

Efficacy of peritoneal dialysis is determined by solute transport through peritoneal membranes. With the use of the peritoneal equilibration test (PET), peritoneal membranes can be classified as high (H), high average (HA), low average (LA), and low (L) transporters, based on the removal or transport rate of solutes, which are small molecules. Whether there is any difference in macromolecules (i.e., proteins) removed by different types of peritoneal membranes remains unclear. We performed a gel-based differential proteomics study of peritoneal dialysate effluents (PDE) obtained from chronic peritoneal dialysis (CPD) patients with H, HA, LA, and L transport rates (n=5 for each group; total n=20). Quantitative analysis and ANOVA with Tukey's posthoc multiple comparisons revealed five proteins whose abundance in PDE significantly differed among groups. These proteins were successfully identified by matrix-assisted laser desorption ionization quadrupole time-of-flight (MALDI-Q-TOF) mass spectrometry (MS) and tandem mass spectrometry (MS/MS) analyses, including serum albumin in a complex with myristic acid and triiodobenzoic acid, alpha1-antitrypsin, complement component C4A, immunoglobulin kappa light chain, and apolipoprotein A-I. The differences among groups in PDE levels of C4A and immunoglobulin kappa were clearly confirmed in a validation set of the other 24 patients (n=6 for each group) using ELISA. These data may lead to better understanding of the physiology of peritoneal membrane transport in CPD patients. Extending the study to a larger number of patients with subgroup analyses may yield additional information of the peritoneal dialysate proteins in association with dialysis adequacy, residual renal function, nutritional status, and risk of peritoneal infection.