Use of arteriovenous fistula in peritoneal dialysis in France (RDPLF data

There is a consensus not to systematically create arteriovenous fistula (AVF) in patients treated with peritoneal dialysis. We wanted to verify in the French Language Peritoneal Dialysis Register (RDPLF) database what the practices are in France. We selected patients who stopped peritoneal dialysis between December 2016 and December 2021 and who, before their peritoneal dialysis treatment, had not been treated with hemodialysis or transplant before. Only 5.2% of patients had an AVF during PD, and 86.7% of these did not use it. Of the patients who did not have AVF, however, 38% were transferred to hemodialysis, often with a central venous catheter. While it is probably important to have a predictive algorithm to avoid definitive transfers in hemodialysis with a central venous catheter when this transfer can be planned, this report confirms the pointlessness of creating a systematic vascular access in PD, particularly when there is a kidney transplant project.

Dipeptidyl peptidase 4 promotes peritoneal fibrosis and its inhibitions prevent failure of peritoneal dialysis

Peritoneal dialysis (PD) possesses multiple advantages for end stage renal disease. However, long-term PD triggers peritoneal fibrosis (PF). From the nationwide analysis of diabetic PD patients (n = 19,828), we identified the incidence of PD failure was significantly lower in diabetic patients treated with dipeptidyl peptidase 4 (DPP4) inhibitors. Experimental study further showed high concentration of glucose remarkably enhanced DPP4 to promote epithelial-mesenchymal transition (EMT) in the mesothelial cells. In chlorhexidine gluconate (CG)-induced PF model of rats, DPP4 expression was enriched at thickening peritoneum. Moreover, as to CG-induced PF model, DPP4 deficiency (F344/DuCrlCrlj strain), sitagliptin and exendin-4 treatments significantly inhibited DPP4 to reverse the EMT process, angiogenesis, oxidative stress, and inflammation, resulting in the protection from PF, preservation of peritoneum and the corresponding functional integrity. Furthermore, DPP4 activity was significantly correlated with peritoneal dysfunction. Taken together, DPP4 caused peritoneal dysfunction/PF, whereas inhibition of DPP4 protected the PD patients against PD failure.

Peritoneal Dialysis and Mortality, Kidney Transplant, and Transition to Hemodialysis: Trends From 1996-2015 in the United States

Rationale & Objective

Transitions between dialysis modalities can be disruptive to care. Our goals were to evaluate rates of transition from peritoneal dialysis (PD) to in-center hemodialysis (HD), mortality, and transplantation among incident PD patients in the US Renal Data System from 1996 to 2015 and identify factors associated with these outcomes.

Study Design

Observational registry-based retrospective cohort study.

Setting & Participants

Medicare patients incident to end-stage renal disease (ESRD) from January 1, 1996, through December 31, 2011 (for adjusted analyses; through December 31, 2014, for unadjusted analyses), and treated with PD 1 or more days within 180 days of ESRD incidence (n = 173,533 for adjusted analyses; n = 219,787 for unadjusted analyses).

Exposure & Predictors

Exposure: 1 or more days of PD. Predictors: patient- and facility-level characteristics obtained from Centers for Medicare & Medicaid Services Form 2728 and other data sources.

Outcomes

Patients were followed up for 3 years until transition to in-center HD, death, or transplantation.

Analytical Approach

Multivariable Cox regression was used to estimate hazards over time and associations with predictors.

Results

Compared with earlier cohorts, recent incident PD patient cohorts had lower rates of death (48% decline) and transition to in-center HD (13% decline). Among many other findings, we found that: (1) rates of transition to in-center HD and death were lowest in the 2008 to 2011 cohort, (2) longer time receiving PD was associated with higher mortality risk but lower risk for transition to in-center HD, and (3) larger PD programs (≥25 vs ≤6 patients) displayed lower risks for death and transition to in-center HD.

Limitations

Data collected on Form 2728 are only at the time of ESRD incidence and do not provide information at the time of transition to in-center HD, death, or transplantation.

Conclusions

Rates of transition from PD to in-center HD and death rates for PD patients decreased over time and were lowest in PD programs with 25 or more patients. Implications of the observed improved technique survival warrant further investigation, focusing on modifiable factors of center-level performance to create opportunities for improved patient outcomes.

Utility of 'back-up' arterio-venous fistulae in patients on peritoneal dialysis and use of haemodialysis catheters

BACKGROUND

Patients undergoing peritoneal dialysis may require unanticipated transfer to haemodialysis. Back up fistula are often created in selected patients. These may help reduce the infective burden of haemodialysis (HD) catheter.

AIM

To study the utility of back-up arterio-venous fistulae (AVF) in patients initiated on peritoneal dialysis (PD) and to determine the rates of HD catheter use in patients requiring conversion to HD.

METHODS

Data on HD transfer and HD catheter usage were retrospectively analysed in all patients initiating PD between January 2010 and December 2014 at Royal Adelaide Hospital (RAH; universal back-up AVF creation at PD commencement) and Princess Alexandra Hospital (PAH; selective back-up AVF creation in 'high risk' patients).

RESULTS

A total of 374 patients initiated PD during the study period: 142 in RAH group and 232 in PAH group. The groups were reasonably comparable, except that RAH patients were more likely to be older, Caucasian and diabetic. Transfer to HD occurred in 33 (23%) patients in RAH group and 99 (43%) in the PAH group with respective median times to HD transfer of 289 and 295 days. HD catheter usage was required at the time of HD transfer in 11 (33%) patients at RAH and 64 (65%) in patients at PAH (P < 0.001). AVF complications occurred in 13 (9%) patients in RAH group (fistuloplasty n = 8, transposition n = 2, ligation due to ischaemia n = 2 and construction of new AVF n = 1).

CONCLUSION

Patients undergoing PD frequently require urgent unanticipated transfer to HD and back-up AVF can be successfully utilised in this setting in the majority of cases, which in turn can reduce the infective burden of HD catheter exposure.

Dialysis initiation, modality choice, access, and prescription: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

Globally, the number of patients undergoing maintenance dialysis is increasing, yet throughout the world there is significant variability in the practice of initiating dialysis. Factors such as availability of resources, reasons for starting dialysis, timing of dialysis initiation, patient education and preparedness, dialysis modality and access, as well as varied "country-specific" factors significantly affect patient experiences and outcomes. As the burden of end-stage kidney disease (ESKD) has increased globally, there has also been a growing recognition of the importance of patient involvement in determining the goals of care and decisions regarding treatment. In January 2018, KDIGO (Kidney Disease: Improving Global Outcomes) convened a Controversies Conference focused on dialysis initiation, including modality choice, access, and prescription. Here we present a summary of the conference discussions, including identified knowledge gaps, areas of controversy, and priorities for research. A major novel theme represented during the conference was the need to move away from a "one-size-fits-all" approach to dialysis and provide more individualized care that incorporates patient goals and preferences while still maintaining best practices for quality and safety. Identifying and including patient-centered goals that can be validated as quality indicators in the context of diverse health care systems to achieve equity of outcomes will require alignment of goals and incentives between patients, providers, regulators, and payers that will vary across health care jurisdictions.

Planning Vascular Access in Peritoneal Dialysis-Defining High-Risk Patients

BACKGROUND

Peritoneal dialysis (PD) is an effective renal replacement technique. However, every year a considerable number of patients are transferred to hemodialysis (HD). Our aim was to identify those at risk, in order to place an arteriovenous fistula (AVF).

METHODS

Case-control study enrolling all prevalent patients in 2014 and 2015 in our clinic. Groups: 72 case patients who were transferred definitively to HD, 111 control patients (remaining on PD, transplanted, recovered renal function, or deceased).

RESULTS

A total of 183 patients were eligible, with a mean age of 55.2 ± 14.8 years, 56.3% male, 31.1% diabetic, and 49.7% on continuous ambulatory PD. The mean follow-up time was 42.1 ± 25.6 months. Eighty-five patients had an AVF. The groups differed in diabetic nephropathy etiology, and in some PD-related characteristics (Kt/V, creatinine clearance, residual renal function, mean ultrafiltration, natriuretic peptide, peritonitis, hospitalizations, and hypervolemia). In multivariate analysis, Kt/V < 1.7 (odds ratio [OR] 3.00, 95% confidence interval [CI]: 1.20 - 7.50], albumin < 35 g/L (OR 4.03, 95% CI: 1.26 - 12.92), number of hospitalizations 1 to 3 (OR 2.74, 95% CI: 1.15 - 6.53) and 4 or more (OR 10.48, 95% CI: 3.62 - 30.36), and 2 or more peritonitis episodes (OR 2.50, 95% CI: 1.03 - 6.07) were predictors of PD transfer to HD. In those patients who were transferred to HD, 34 initiated HD by AVF, 2 needed a catheter due to a non-functioning AVF, and 36 did not have an AVF needing catheter placement.

CONCLUSIONS

Low Kt/V, low albumin, higher number of hospitalizations, and peritonitis were factors associated with PD transfer to HD, probably indicative of a high-risk PD population where arteriovenous access should be weighed.

Dialysis access: issues related to conversion from peritoneal dialysis to hemodialysis and vice versa

Hemodialysis (HD) and peritoneal dialysis (PD) represent two complementary modalities of renal replacement therapy (RRT) for end-stage renal disease patients. Conversion between the two modalities is frequent and more likely to happen from PD to HD. Every year, 10% of PD patients convert to HD, suggesting the need for recommendations on how to proceed with the creation of a vascular access in these patients. Criteria for selecting patients who would likely fail PD, and therefore take advantage of a backup access, are undefined. Creating backup fistulas at the time of PD treatment start to allow emergency access for HD has proved to be inefficient, but it may be considered in patients with progressive difficulty in achieving adequate depuration and/or peritoneal ultrafiltration. A big challenge is represented by patients switching from PD to HD for unexpected infectious complications. Those patients need to start HD with a central venous catheter (CVC), but an alternative approach might be using an early cannulation graft, provided that infection has been cleared by the circulation. An early cannulation graft might also be used to considerably shorten the time spent using a CVC. In patients who need a conversion from HD to PD, urgent-start PD is now an accepted and well-established approach.

Surface modification strategies for combating catheter-related complications: recent advances and challenges

This review summarizes the progress made in addressing bacterial colonization and other surface-related complications arising from catheter use.

Predictors and outcomes of transfers from peritoneal dialysis to hemodialysis

INTRODUCTION

Peritoneal dialysis (PD) patients are commonly required to transfer to hemodialysis (HD), however the literature describing the outcomes of such transfers is limited. The aim of our study was to describe the predictors of these transfers and their outcomes according to vascular access at the time of transfer.

METHODS

A retrospective cohort study using registry data of all adult patients commencing PD as their initial renal replacement therapy in Australia or New Zealand between 2004 - 2010 was performed. Follow-up was until 31 December 2010. Logistic regression models were constructed to determine possible predictors of transfer within both 6 and 12 months of PD commencement. Cox analysis and competing risks regression were used to determine the predictors of survival and transplantation post-transfer.

RESULTS

The analysis included 4,781 incident PD patients, of whom 1,699 transferred to HD during the study period. Logistic models did not identify any clinically useful predictors of transfer within 6 or 12 months (c-statistics 0.54 and 0.55 respectively). 67% of patients commenced HD with a central venous catheter (CVC). CVC use at transfer was associated with increased mortality (hazard ratio 1.37, 95% confidence interval (CI) 1.11 - 1.68, p = 0.003) and a borderline significant reduction in the incidence of transplantation (subhazard ratio 0.76, 95% CI 0.58 - 1.00, p = 0.05).

CONCLUSIONS

It is difficult to predict the transfer to HD for incident PD patients. PD patients who commence HD with a CVC have a higher risk of mortality and a lower likelihood of undergoing renal transplantation.

Is transition between peritoneal dialysis and hemodialysis really a gradual process?

BACKGROUND

Transfer to hemodialysis (HD) is a frequent cause of peritoneal dialysis (PD) cessation. In the present study, we set out to describe the transition period between PD and HD.

METHODS

All patients in 4 centers of Basse-Normandie who had been treated with PD for more than 90 days and who were permanently transferred to HD between 1 January 2005 and 31 December 2009 were retrospectively reviewed. The rate of unplanned HD start was evaluated.

RESULTS

In the 60 patients (39 men, 21 women) included in the study, median score on the Charlson comorbidity index at PD initiation was 5 [interquartile range (IQR): 3 - 7], median age at HD initiation was 62 years (IQR: 54 - 76 years), and median duration on PD was 22 months (IQR: 12 - 36 months). Among the 60 patients, 37 had an unplanned HD initiation. Peritonitis was the most frequent cause of unplanned HD start (n = 20), and dialysis inadequacy (n = 11), the main cause of planned HD start. During the transition period, all patients were hospitalized. Median duration of hospitalization was 4.5 days (IQR: 0 - 25.5 days). Within 2 months after HD initiation, 9 patients died. Two months after starting HD, 6 of the remaining 51 patients were being treated in a self-care HD unit and only 23 patients had a mature fistula.

CONCLUSIONS

Unplanned HD start is a common problem in patients transferred from PD. Further studies are needed to improve the rate of planned HD start in PD patients transferred to HD.

Optimizing AVF creation prior to dialysis start: the role of predialysis renal replacement therapy choices

BACKGROUND

In British Columbia, multidisciplinary predialysis clinics encourage patients to consider independent modalities of renal replacement therapy (RRT) such as peritoneal dialysis (PD) 'first'. Despite up to 50% of patients choosing PD, PD incidence rates are ~30%. We explored the relationship between predialysis RRT choice and arteriovenous fistula (AVF) creation prior to hemodialysis (HD) start with particular focus on the group of patients who despite PD choice actually commence HD, and thus may contribute to 'suboptimal' HD starts without AVF creation.

METHODS

We conducted a retrospective cohort study of all patients starting dialysis between 31 December, 2006 and 31 December 2008 in the province of British Columbia. Inclusion criteria were >3 months predialysis nephrology follow-up, at least one predialysis RRT education session and maintenance on dialysis for a minimum of 3 months (to ensure chronic dialysis). Patients with any prior history of RRT were excluded.

RESULTS

There were 508 patients included in the study: 127 (25%) patients chose HD, 114 (22%) PD, 13 (3%) pre-emptive transplant, 5 (1%) conservative management and 249 (49%) had no documented modality decision. Of those who chose HD, 94% commenced HD. For those who chose PD, 64% commenced PD and 36% HD. In the undecided group, 68% started HD and 32% PD. For those patients who chose PD predialysis, the presence of cardiovascular disease [odds ratio (OR) 2.36, 95% confidence interval (CI) 1.02-5.43] and lower serum albumin levels (OR 0.92, 95% CI 0.86-0.98) were associated with failure to commence PD. Predialysis AVF creation rates were 79% of those who chose and started HD, 39% of those who chose PD but started HD and 50% of those in the undecided group who commenced HD.

CONCLUSIONS

AVF creation rates prior to HD start were lower in those patients with no documented dialysis modality choice and in those who failed to commence PD. Cardiovascular disease and lower serum albumin levels were associated with failure to start PD. Further work to ensure the efficacy of RRT modality choice pathway and to better predict those patients who will fail to commence PD is necessary, so that dialysis start can be 'optimized' with AVF creation in high-risk groups.