Dialysis Modality and Incident Stroke Among Patients With End-Stage Kidney Disease: A Registry-Based Cohort Study

BACKGROUND

Patients with end-stage kidney disease undergoing dialysis are at significant risk of stroke. Whether dialysis modality is associated with cerebrovascular disease is unclear. This study compared the risk of incident stroke in patients undergoing peritoneal dialysis or hemodialysis.

METHODS

Thirty-nine thousand five hundred forty-two patients without a history of stroke who initiated dialysis between January 1, 2010, and December 31, 2014 were retrospectively studied using Taiwan's National Health Insurance Research Database. We matched 3809 patients undergoing peritoneal dialysis (mean age 59±13 years; 46.5% women) and 11 427 patients undergoing hemodialysis (mean age 59±13 years; 47.3% women) by propensity score in a 1:3 ratio with follow-up through December 31, 2015. The primary outcome was incident acute ischemic stroke. Secondary outcomes included hemorrhagic stroke, acute coronary syndrome, and all-cause mortality. Cox proportional hazard models were conducted to determine hazard ratios of clinical outcomes according to the dialysis modality.

RESULTS

During a median follow-up of 2.59 (interquartile range 1.50-3.93) years, acute ischemic stroke, hemorrhagic stroke, and acute coronary syndrome occurred in 783 (5.1%), 376 (2.5%), and 1350 (8.9%) patients, respectively. In a multivariable Cox model that accounted for the competing risk of death, acute ischemic stroke occurred more frequently in the peritoneal dialysis group than in the hemodialysis group (subdistribution hazard ratio, 1.32 [95% CI, 1.13-1.54]; P=0.0005). There were no significant treatment-related differences in the risk of hemorrhagic stroke (subdistribution hazard ratio, 0.89 [95% CI, 0.70-1.14]; P=0.3571) and acute coronary syndrome (subdistribution hazard ratio, 0.99 [95% CI, 0.88-1.12]; P=0.9080). Patients undergoing peritoneal dialysis were more likely to die from any cause than patients undergoing hemodialysis (adjusted hazard ratio, 1.24 [95% CI, 1.15-1.33]; P<0.0001).

CONCLUSIONS

Peritoneal dialysis was associated with a significantly increased risk of acute ischemic stroke compared with hemodialysis. Further studies are needed to clarify whether more aggressive cerebrovascular preventive strategies might mitigate the excess risk for ischemic stroke among patients receiving peritoneal dialysis.

Impact of initial dialysis modality on the survival of patients with ESRD: a propensity-score-matched study

BACKGROUND

Studies comparing the survival of hemodialysis (HD) and peritoneal dialysis (PD) patients are controversial. This study evaluated the impact of initial dialysis modality on the survival of patients with end-stage renal disease (ESRD) in a matched-pair cohort.

METHODS

A retrospective cohort study was performed on ESRD patients who initiated renal replacement treatment between January 1, 2010, and December 31, 2018. Propensity score matching was applied to balance the baseline conditions, and multivariate Cox regression analysis was applied to compare mortality between HD and PD patients and evaluate correlations between mortality and various baseline characteristics. Subgroup analysis was performed with respect to diabetes status.

RESULTS

There were 739 patients in our center in the Chinese National Renal Data System (CNRDS) between 2010 and 2018. Of these, 125 PD patients were matched with 125 HD patients. The 1-, 2-, and 3-year survival rates were 96.5%, 90.7%, and 82.5%, respectively, in the HD group and 99.5%, 97.8%, and 92.5%, respectively, in the PD group (log-rank P < 0.001). Among the propensity score-matched cohorts, no significant differences in Kaplan-Meier curves were observed between the two groups (log-rank P = 0.514). Age at dialysis initiation, CCI, congestive heart failure and cerebrovascular disease were risk factors in the multivariable-adjusted model. In subgroups defined by diabetes status, the Kaplan‒Meier survival curve showed that PD survival was significantly higher than that of HD (log-rank P = 0.022).

CONCLUSIONS

HD and PD were not significantly different regarding the survival of patients with ESRD. PD was associated with better survival in diabetic ESRD patients.

Characteristics and 1-year survival of incident patients on chronic peritoneal dialysis compared with hemodialysis:a large 11-year cohort study

PURPOSE

Few studies have evaluated patients' characteristics and survival by dialysis modality in Brazil. We evaluated changes in dialysis modality and its survival in the country.

METHODS

This is a retrospective database of a cohort with incident chronic dialysis patients from Brazil. Patients' characteristics and one-year multivariate survival risk were assessed considering dialysis modality from 2011 to 2016 and 2017 to 2021. Survival analysis was also performed on a reduced sample after adjustment using propensity score matching.

RESULTS

Of the 8295 dialysis patients, 5.3% were on peritoneal dialysis (PD) and 94.7% on hemodialysis (HD). PD patients had higher BMI, schooling and the prevalence of elective dialysis starting in the first period than those on HD. In the second period, PD patients were predominantly women, non-white, from the Southeast region, and funded by the public health system, having more frequent elective dialysis starting and predialysis nephrologist follow-ups than those on HD. There was no difference in mortality comparing PD and HD (HR 0.67, 95% CI 0.39-2.42; and HR 1.17, 95% CI 0.63-2.16; first and second period, respectively). This non-significantly different survival between both dialysis methods was also found in the reduced matched sample. Higher age and non-elective dialysis initiation were associated with higher mortality. In the second period, the lack of predialysis nephrologist follow-up and living in the Southeast region increased the mortality risk.

CONCLUSION

Some sociodemographic factors have changed according to dialysis modality over the last decade in Brazil. The one-year survival of the two dialysis methods was comparable.

Patients with end-stage renal disease and diabetes had similar survival rates whether they received hemodialysis or peritoneal dialysis

BACKGROUND

The survival rate of patients with diabetes mellitus (DM) and end-stage renal disease (ESRD) undergoing maintenance dialysis, including hemodialysis (HD) and peritoneal dialysis (PD), is markedly lower than that observed in patients with ESRD without DM.

METHODS

We used propensity score matching to balance the clinical characteristics of patients from the HD and PD groups. We compared the survival rate between HD or PD, followed by Cox regression analyses accounting for age, Charlson comorbidity index (CCI), body mass index (BMI), and serum albumin levels to examine the outcome influence of dialysis modalities.

RESULTS

During follow-up, there were 19 (18.1%) and 18 (17.1%) deaths among patients who underwent HD and PD, respectively (P = 0.856). Kaplan-Meier survival analyses showed no significant difference in overall survival between patients in the HD and PD groups. Cox regression analyses stratified based on age, CCI, BMI, and serum albumin demonstrated that the choice of HD over PD did not influence survival.

CONCLUSIONS

Regardless of age, CCI, BMI, and albumin level, patients with DM and ESRD had similar survival rates whether they received HD or PD in China. The choice of dialysis modality should be individualized according to patients' physical status and local practices for patients with DM and ESRD.

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.

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.

Survival analysis in the incident dialysis patients by different modalities

BACKGROUND

To analysis survival in onset uremic patients who initiating HD or PD dialysis in our dialysis center.

METHODS

Between Jan. 2015 and June. 2018, patients with onset uremia and initiating planned-start dialysis were retrospectively enrolled in this study and followed up to January, 2019. The relationships between the types of dialysis modality and patient prognosis were assessed.

RESULTS

A total of 460 patients were included in the final analysis. Of which, 213 patient (46.30%) undergoing PD and 247 patients (53.70%) undergoing HD with arteriovenous fistula. The average follow-up time was 27.9 months. Eighty-seven (18.91%) patients died during the study period. The all-cause mortality was 127 per 1000 person-year. It was 102 per 1000 person-year in the HD group and 171 per 1000 person-year in the PD group (p < 0.01). However, dialysis modality was not an independent predictor for survival. During the first year after dialysis initiation, patient survival was comparable between the PD and HD groups (log-rank p = 0.14). As the dialysis age increased over 1 year, HD patients seemed to have a better survival as compared to that of PD patient (log-rank p < 0.05), especially those older than 65 years and without DN.

CONCLUSIONS

Though dialysis modality was not an independent factor for overall survival, HD therapy seemed to be more suitable for patients without DN.

Home Versus Facility Dialysis and Mortality in Australia and New Zealand

RATIONALE & OBJECTIVE

Mortality is an important outcome for all dialysis stakeholders. We examined associations between dialysis modality and mortality in the modern era.

STUDY DESIGN

Observational study comparing dialysis inception cohorts 1998-2002, 2003-2007, 2008-2012, and 2013-2017.

SETTING & PARTICIPANTS

Australia and New Zealand (ANZ) dialysis population.

EXPOSURE

The primary exposure was dialysis modality: facility hemodialysis (HD), continuous ambulatory peritoneal dialysis (CAPD), automated PD (APD), or home HD.

OUTCOME

The main outcome was death.

ANALYTICAL METHODS

Cause-specific proportional hazards models with shared frailty and subdistribution proportional hazards (Fine and Gray) models, adjusting for available confounding covariates.

RESULTS

In 52,097 patients, the overall death rate improved from ~15 deaths per 100 patient-years in 1998-2002 to ~11 in 2013-2017, with the largest cause-specific contribution from decreased infectious death. Relative to facility HD, mortality with CAPD and APD has improved over the years, with adjusted hazard ratios in 2013-2017 of 0.88 (95% CI, 0.78-0.99) and 0.91 (95% CI, 0.82-1.00), respectively. Increasingly, patients with lower clinical risk have been adopting APD, and to a lesser extent CAPD. Relative to facility HD, mortality with home HD was lower throughout the entire period of observation, despite increasing adoption by older patients and those with more comorbidities. All effects were generally insensitive to the modeling approach (initial vs time-varying modality, cause-specific versus subdistribution regression), different follow-up time intervals (5 year vs 7 year vs 10 year). There was no effect modification by diabetes, comorbidity, or sex.

LIMITATIONS

Potential for residual confounding, limited generalizability.

CONCLUSIONS

The survival of patients on PD in 2013-2017 appears greater than the survival for patients on facility HD in ANZ. Additional research is needed to assess whether changing clinical risk profiles over time, varied dialysis prescription, and morbidity from dialysis access contribute to these findings.

Impact of initial dialysis modality on the survival of patients with ESRD in eastern China: a propensity-matched study

Background

There are conflicting research results about the survival differences between hemodialysis(HD) and peritoneal dialysis (PD). The present study estimated the survival and the relative mortality hazard for incident HD and PD patients with end stage renal disease (ESRD) in eastern China.

Methods

This study examined a cohort of patients with ESRD who initiated dialysis therapy in Zhejiang province between Jan of 2010 and Dec of 2014, followed up until the end of 2015. PD patients were matched in a 1:1 fashion with HD patients, and Kaplan–Meier analysis was used to explore the survival of them. The Cox proportional hazard regression model was applied to identify the factors that predict survival by treatment modality. Subgroup analyses were conducted by stratifying patients according to gender, age, causes of ESRD and comorbidities.

Results

Among a total of 22,379 enrolled patients (17,029 HD patients and 5350 PD patients), 5350 matched pairs were identified, and followed for a median of 29 months (3 ~ 72 months). Kaplan-Meier survival curve revealed that overall mortality rate was significantly higher in HD patients than in PD patients (log-rank test, P < 0.001), after adjusting by gender, age, primary causes of ESRD and comorbidities. HD was consistently associated with an increased risk for morality compared with PD in the matched cohort (adjusted hazard ratio (AHR): 1.140, 95%CI: 1.023 ~ 1.271). In subgroup analyses, male, younger patients, or nondiabetic patients aged less than 65 years after adjustment of covariates, initiating with PD was associated with a significantly lower mortality compared with HD. In the multivariate Cox proportional risks model, age, diabetic nephropathy (DN), other/unknown causes of ESRD, and patients with a history of cardiovascular disease or cancer showed statistical significance in explaining survival of incident ESRD patients.

Conclusions

ESRD patients who initiated dialysis with PD yielded superior survival rates compared to HD. Increased use of PD as initial dialysis modality in ESRD patients could be encouraged in Chinese population.

Changes in mortality hazard of the Korean long-term dialysis population: The dependencies of time and modality switch

BACKGROUND

Many studies have compared patient survival outcome between hemodialysis (HD) and peritoneal dialysis (PD); however, time-varying risks of dialysis modality have been rarely investigated. This study aimed to investigate dialysis modality switch and its association with the survival outcome in the Korean population.

METHODS

Data from the Korean Society of Nephrology were used. A total of 21,840 incident dialysis patients who started dialysis in or after 2000 were analyzed. For the survival analysis, both proportional and non-proportional hazard assumptions were applied. For the modality switch, time-varying covariate Cox regression was applied.

RESULTS

During the median follow-up of 8 years, PD group showed increased adjusted hazard ratio (HR) of 1.248 (95% CI 1.071-1.454, p = 0.004) for mortality. Interaction of PD status with female sex was significant with an HR of 1.080 (95% CI 1.000-1.165, p = 0.050). Dialysis modality switch was associated with increased HR of 1.094 (95% CI 1.015-1.180, p = 0.019), albeit switch from PD to HD did not show significant HR until 6 years. Interestingly, time-varying risk analysis showed a decreased HR of PD after 10 years in the non-switcher group, which was consistent in patients with high traditional risk factors (with diabetes, elderly).

CONCLUSIONS

PD was associated with increased HR of mortality in the first 8 years, then it was associated with decreased HR of mortality after 10 years. Dialysis modality switch was associated with increased mortality risk, but switch from PD to HD within 6 years did not show significant hazard of mortality.

The benefit of early survival on PD versus HD—Why this is (still) very important

There are a number of misconceptions around the identified early survival benefit of peritoneal dialysis (PD) relative to hemodialysis (HD), including that such benefits “even out in the end” since the relative risk of death over time eventually encompasses 1.0 (or even an estimate that is unfavorable to PD); that the early benefit is, in fact, most likely due to unmeasured confounding; and such benefits are only due to the influence of central venous catheters and “crash starters” in the HD group. In fact, the early survival benefit results in a substantial gain of patient life years in PD cohorts relative to HD ones, even if it the benefit appears to “even out in the end,” is relatively insensitive to unmeasured confounding, and persists even when the effects of central venous catheters are accounted for. In this review, the calculations and arguments are made to support these tenets. Survival on dialysis is still one of the most important considerations for all stakeholders in the end-stage kidney disease community, including patients who rank it among their top priorities. Shared decision-making is a fundamental patient right and requires both balanced information and an iterative mechanism for a consensual decision based on shared understanding and purpose. A cornerstone of this process should be an explicit discussion of the early survival benefit of PD relative to HD.

Survival Analysis and Associated Factors in THAI Patients on Peritoneal Dialysis under the PD-First Policy

Background

The peritoneal dialysis First (PD-First) policy means that PD is the first modality of dialysis chosen for patients with end-stage renal disease (ESRD), as put forth by the Universal Health Coverage (UHC) scheme. It was initiated in Thailand in 2008. Our aim is to analyze patient survival, technique survival, and associated factors.

Methods

Data of PD patients from January 2008 to November 2016 were studied. We calculated patient and technique survival rates (censored for death and kidney transplantation). Factors associated with survival were analyzed by the Cox proportional hazard model. Patient and technique survival rates between 2008 – 2012 and 2013 – 2016 were compared.

Results

Our study included 11,477 patients. The mean (standard deviation [SD]) age at initiation of PD was 54.0 (14.4) years. The level of education in 85.2% of cases was illiterate or primary school. A total of 60.9% of patients developed ESRD secondary to diabetes. The 1- to 5-year patient survival rates were 82.6, 71.8, 64.0, 58.5, and 54.0%, respectively. The first-year technique survival rate was 94.8%. The patient and technique survival rates during 2013 – 2016 were better than those seen during 2008 – 2012. Factors associated with lower patient survival rates were: female gender, increased age at start of PD, coverage with civil servant medical benefit scheme, low educational levels, and a history of diabetes.

Conclusion

Most patients had diabetes and low educational levels as seen in the outcomes in the previous literature. These factors impacted the survival of patients under the PD-First policy.

A comparison of quality of life between patients treated with different dialysis modalities in Taiwan

Purpose

This study compared the quality of life (QOL) of hemodialysis (HD) and peritoneal dialysis (PD) patients in Taiwan.

Methods

This cross-sectional study recruited end-stage renal disease patients from 34 Taiwanese hospitals or clinics. Patient characteristics, diagnoses, and laboratory data were extracted from charts. The Chinese version of the Quality of Life Index–Dialysis version (QLI-D) was used. Multiple linear regression analysis showed the effects of dialysis modality on QOL. P<0.05 indicated statistical significance.

Results

In total, 600 HD and 387 PD patients were included. The mean health and functioning, social and economic, psychological/spiritual, and family subscale scores and total QOL scores were significantly lower in HD patients than PD patients. After adjusting for region, hospital level, age, education level, marital status, and Karnofsky Performance Scale, the total QOL was 2.81 points higher for PD patients than for HD patients visiting medical centers (p<0.001). The total QOL was 2.53 points lower in PD patients than in HD patients for those visiting clinics.

Conclusion

Compared to HD patients, PD patients had better QOL in Taiwanese medical centers. The current survey improves our understanding of the QOL of patients undergoing different dialysis modalities in Taiwan.

Comparison of peritoneal dialysis with hemodialysis on survival of diabetic patients with end-stage kidney disease: a meta-analysis of cohort studies

Aim: Renal replacement therapy was primary treatment for end stage kidney (ESRD) patients. Numbers of studies comparing peritoneal dialysis (PD) and hemodialysis (HD) yielded inconsistent results. The aim of this study was to assess the mortality risk between diabetic PD patients and those in HD.

Methods: We included cohort studies comparing the risk of death among diabetic ESRD patients who receiving peritoneal dialysis or hemodialysis by searching Medline and Embase. Overall estimates were calculated using the random-effects model.

Results: Seventeen studies were included in the meta-analyses. Mortality comparison between PD and HD in the diabetic ESRD patients showed PD significantly increased mortality rate (hazard ratio (HR) 1.20; 95% confidence interval (CI) 1.10–1.30; I² = 89.1%). The overall HR using an intention-to-treat analysis was 1.23 with 95% CI (1.13 to 1.34). Meta-regression demonstrated PD patients from Asian country were associated with increase in mortality risk (coefficient = 0.270, SE = 0.112, p = .033).

Limitation: The high heterogeneity in our meta-analyses undermined the robustness of the findings.

Conclusion: ESRD patients with diabetes may benefit more from HD than PD.

An integrated model using the Taguchi method and artificial neural network to improve artificial kidney solidification parameters

BACKGROUND

Hemodialysis mainly relies on the "artificial kidney," which plays a very important role in temporarily or permanently substituting for the kidney to carry out the exchange of waste and discharge of water. Nevertheless, a previous study on the artificial kidney has paid little attention to the optimization of factors and levels for reducing the solidification of the artificial kidney during the hemodialysis procedure. Thus, this study proposes an integrated model that uses the Taguchi method, omega formula, and back-propagation network to determine the optimal factors and levels for addressing this issue.

METHODS

First, we collected the recommendations of medical doctors and nursing staff through a small group discussion, and used the Taguchi method to analyze the key factors at different levels. Next, the omega formula was used to convert the analysis results from the Taguchi method to assess the defect rate. Finally, we utilized back-propagation network algorithms to predict the optimal factors and levels for artificial kidney solidification, in order to confirm that the key factors and levels identified can effectively improve the solidification rate of the artificial kidney and thereby enhance the effect of hemodialysis.

RESULTS

The research finding proposes the following as the optimal factors and levels for artificial kidney solidification: the amount of anticoagulation should be set at 500 units, the velocity of blood flow at 300 ml/min, the dehydration volume at 2.5 kg, and the vascular access type as autologous blood vessels. We obtained 270 sets of data from the patients of End Stage Renal Disease (ESRD) under the setting of the optimal combination of the factors at different levels; the defect rate of artificial kidney solidification is 12.9%, which is better than the defect rate of 32% in the original experiment. Meanwhile, the patient characteristics for physiological status in BMI, serum calcium, hematocrit, ferritin, and transferrin saturation percentage are improved by this study.

CONCLUSION

This conclusion validates the ability of the proposed model in this study to improve the solidification rate of the artificial kidney, thereby confirming the model's use as a standard operation procedure in the hemodialysis experiment. The ideas behind and the implications of the proposed model are further discussed in this study.

Propensity Score-Matched Analysis of the Survival Benefit from Kidney Transplantation in Patients with End-Stage Renal Disease

BACKGROUND

Several comparison studies have suggested that kidney transplantation (KT) could reduce mortality in patients with end-stage renal disease (ESRD). Selection criteria bias is common in the selection of dialysis patients for control groups. In this study, we compared the survival outcome between KT recipients and comparable propensity score-matched dialysis patients.

METHODS

We used Taiwan's National Health Insurance Research Database to identify patients newly diagnosed with ESRD between 2000 and 2010. We separated them into two groups: a KT group and non-KT dialysis-only group. To evaluate the survival outcome, we compared each patient with KT to a patient on dialysis without KT using propensity score matching.

RESULTS

In total, 1276 KT recipients and 1276 propensity score-matched dialysis patients were identified. Compared with the propensity score-matched dialysis patients, the patients who underwent KT exhibited significantly higher 5-year and 10-year survival rates (88% vs. 92% and 74% vs. 87%, both p < 0.05). The crude and adjusted hazard ratios for mortality were 0.55 and 0.52 in patients with KT (both p < 0.001). Mortality was insignificantly higher for patients who were on dialysis for longer than 1 year prior to KT compared with those on dialysis for less than 1 year.

CONCLUSION

This study used a propensity score-matched cohort to confirm that KT is associated with lower risk of mortality than dialysis alone in patients newly diagnosed with ESRD.

The influence of renal dialysis and hip fracture sites on the 10-year mortality of elderly hip fracture patients: A nationwide population-based observational study

Hip fractures in older people requiring dialysis are associated with high mortality. Our study primarily aimed to evaluate the specific burden of dialysis on the mortality rate following hip fracture. The secondary aim was to clarify the effect of the fracture site on mortality. A retrospective cohort study was conducted using Taiwan's National Health Insurance Research Database to analyze nationwide health data regarding dialysis and non-dialysis patients ≥65 years who sustained a first fragility-related hip fracture during the period from 2001 to 2005. Each dialysis hip fracture patient was age- and sex-matched to 5 non-dialysis hip fracture patients to construct the matched cohort. Survival status of patients was followed-up until death or the end of 2011. Survival analyses using multivariate Cox proportional hazards models and the Kaplan-Meier estimator were performed to compare between-group survival and impact of hip fracture sites on mortality. A total of 61,346 hip fracture patients were included nationwide. Among them, 997 dialysis hip fracture patients were identified and matched to 4985 non-dialysis hip fracture patients. Mortality events were 155, 188, 464, and 103 in the dialysis group, and 314, 382, 1505, and 284 in the non-dialysis group, with adjusted hazard ratios (associated 95% confidence intervals) of 2.58 (2.13-3.13), 2.95 (2.48-3.51), 2.84 (2.55-3.15), and 2.39 (1.94-2.93) at 0 to 3 months, 3 months to 1 year, 1 to 6 years, and 6 to 10 years after the fracture, respectively. In the non-dialysis group, survival was consistently better for patients who sustained femoral neck fractures compared to trochanteric fractures (0-10 years' log-rank test, P < .001). In the dialysis group, survival of patients with femoral neck fractures was better than that of patients with trochanteric fractures only within the first 6 years post-fracture (0-6 years' log-rank, P < .001). Dialysis was a significant risk factor of mortality in geriatric hip fracture patients. Survival outcome was better for non-dialysis patients with femoral neck fractures compared to those with trochanteric fractures throughout 10 years. However, the survival advantage of femoral neck fractures was limited to the first 6 years postinjury among dialysis patients.

1,25(OH)2D3 treatment attenuates high glucose‑induced peritoneal epithelial to mesenchymal transition in mice

It has been previously demonstrated that 1,25(OH)2D3 prevents the progression of epithelial to mesenchymal transition (EMT). However, it remains unclear whether 1,25(OH)2D3 has a role in peritoneal EMT stimulated by high glucose (HG) peritoneal dialysis fluid (PDF). The present study was performed to investigate the role of 1,25(OH)2D3 in the progression of EMT in the peritoneal mesothelium. A total of 35 male Kunming mice were randomly assigned into seven groups. In the control group, no diasylate or saline was infused. In the saline group, the mice were intraperitoneally injected with saline every day for 4 weeks. In the vitamin D group, the mice were subjected to intraperitoneal injections of 1 or 5 µg/kg of 1,25(OH)2D3 once weekly (every Monday) for 4 weeks. The peritoneal dialysis (PD) group were intraperitoneally injected with a conventional 4.25% PDF daily for 4 weeks. The vitamin D+PD group were intraperitoneally injected with 4.25% PDF daily and co‑treated with 1 µg/kg or 5 µg/kg 1,25(OH)2D3 once weekly, for 4 weeks. The peritoneal morphology and thickness were assessed by hematoxylin and eosin and Masson's trichrome staining. The peritoneal protein level of EMT markers (α‑smooth muscle actin, fibronectin and E‑cadherin), vitamin D receptor (VDR), B cell lymphoma‑2 (Bcl‑2), Bcl‑2‑associated X protein, transforming growth factor (TGF)‑β and Smad3 were evaluated by western blot analysis or immunohistochemical staining. Furthermore, apoptosis was assessed using a Caspase‑3 activity assay. The results demonstrated that after 4 weeks of intraperitoneal injections in mice, HG‑PDF decreased the expression of VDR, promoted EMT and apoptosis, and increased the thickness of the peritoneal membrane. However, 1,25(OH)2D3 treatment attenuated HG‑induced EMT and apoptosis, and decreased peritoneal thickness, which may partially occur through inhibition of transforming growth factor TGF‑β/Smad pathways via 1,25(OH)2D3 binding to VDR. The present study demonstrated that 1,25(OH)2D3 attenuated HG‑induced EMT and apoptosis in the peritoneal mesothelium through TGF‑β/Smad pathways. 1,25(OH)2D3 treatment in conjunction with HG dialysate may provide an improved solution to the peritoneal injury in the process of PD.

Cardiovascular impact in patients undergoing maintenance hemodialysis: Clinical management considerations

Patients undergoing maintenance hemodialysis develop both structural and functional cardiovascular abnormalities. Despite improvement of dialysis technology, cardiovascular mortality of this population remains high. The pathophysiological mechanisms of these changes are complex and not well understood. It has been postulated that several non-traditional, uremic-related risk factors, especially the long-term uremic state, which may affect the cardiovascular system. There are many cardiovascular changes that occur in chronic kidney disease including left ventricular hypertrophy, myocardial fibrosis, microvascular disease, accelerated atherosclerosis and arteriosclerosis. These structural and functional changes in patients receiving chronic dialysis make them more susceptible to myocardial ischemia. Hemodialysis itself may adversely affect the cardiovascular system due to non-physiologic fluid removal, leading to hemodynamic instability and initiation of systemic inflammation. In the past decade there has been growing awareness that pathophysiological mechanisms cause cardiovascular dysfunction in patients on chronic dialysis, and there are now pharmacological and non-pharmacological therapies that may improve the poor quality of life and high mortality rate that these patients experience.

Different effect of hypercholesterolemia on mortality in hemodialysis patients based on coronary artery disease or myocardial infarction

Background

Studies on the association of total cholesterol (TC) levels and mortality in hemodialysis (HD) patients demonstrated conflicting results. The differenct effect of Hypercholesterolemia on HD patients based on the presence of myocardial infarction (MI) or coronary artery disease (CAD) is unknown.

Methods

We analyzed data from the Taiwan Renal Registry Data System (TWRDS) between 2005 and 2012. Patients were divided into MI/CAD or non-MI/CAD group. The primary outcome was three-year mortality. The association between primary outcome and first year average TC and effect of change in cholesterol level between the first and third year of dialysis were explored.

Results

Of 90,795 HD patients, 77,762 (85.6%) patients were assigned to non-MI/CAD group and 13,033 (14.4%) to the MI/CAD group. In the non-MI/CAD subjects, both TC > 250 mg/dL and < 150 mg/dL were associated with increased risk of mortality (adjusted hazard ratio [HR]; 95% confidence interval [CI]: 1.27; 1.17–1.37 and 1.14; 1.11–1.18) compared to the reference (TC: 150–200 mg/dL). In the MI/CAD patients, only TC < 150 mg/dL had increased risk (HR; 95% CI: 1.15; 1.08–1.24). In addition, patients of the non-MI/CAD group with highest level of TC (>250 mg/dL) in both first and third year of dialysis had a 64% increased risk for mortality (HR: 1.64, 95% CI: 1.51–1.80).

Conclusion

In this nationwide hemodialysis cohort, hypercholesterolemia was associated with increased mortality in HD patients without MI/CAD. Further investigation on primary prevention of CAD with statin is warranted.

Patient and Technique Survival of Older Adults with ESRD Treated with Peritoneal Dialysis

The number of older adults worldwide is increasing as societies gain success in improving the health and lifespan of their citizens. As a result, increasing numbers of older adults are presenting to the medical community with advanced kidney failure. Historically, dialysis treatments were withheld from older adults particularly those with severe co-existing illnesses. This has changed in most parts of the world, and there is now an increasing emphasis on shared decision-making to determine whether dialysis is appropriate and to determine which modality meets the needs, expectations, and desire of patients. Evidence examining the difference in risk for death of older adults treated with hemodialysis (HD) or peritoneal dialysis (PD), and the probability of those treated with PD to transfer to HD among older compared to younger adults, is largely derived from prospective cohort studies or analyses of data from national registries. In such studies, it is difficult to distinguish whether differences in outcomes reflect the effect of dialysis modality or differences in health status of different groups of patients. Longevity and technique survival are important, albeit not the only or most important consideration in such decision-making. Given the risk for bias in observational studies and the profound effect of dialysis modality on patients' lifestyle, the selection of dialysis modality should remain a decision made by the patient, caregivers, and his/her physician after thorough education and review of the available data.

Determinant Effects of Average Fasting Plasma Glucose on Mortality in Diabetic End-Stage Renal Disease Patients on Maintenance Hemodialysis

Introduction

Diabetic kidney disease is an increasingly frequent cause of end-stage renal disease. However, mixed results were shown between glycated hemoglobin and mortality.

Methods

We used the average fasting plasma glucose (FPG) levels to predict mortality rates in long-term hemodialysis patients. We enrolled 46,332 hemodialysis patients with diabetes mellitus, who were registered in the Taiwan Renal Registry Data System between January 2005 and December 2012. The patients were stratified based on the quartiles of average FPG levels measured for the first (1-year FPG) and third years (3-year FPG) of hemodialysis. Survival analysis was conducted via multivariable Cox regression.

Results

After the first year of hemodialysis, the mean FPG levels were 103.5 ± 14.5, 144.7 ± 11.5, 189.6 ± 15.2, and 280.8 ± 1.2 mg/dl for the first, second, third, and fourth quartile, respectively. The Kaplan-Meier curve showed an incremental reduction in the survival as FPG levels increased (P < 0.0001). In the Cox regression model, the adjusted hazard ratios were 1.15 (95% CI: 1.10–1.20), 1.30 (95% CI: 1.25–1.36), and 1.45 (95% CI: 1.39–1.51) for the pairwise comparisons between the first quartile and the second, third, and fourth quartile, respectively. Similar trends were observed by 3-year FPG. Patients whose FPG levels increased had a 22% increased risk (95% CI: 1.16–1.29) for all-cause mortality compared with patients whose FPG levels decreased.

Discussion

Our results suggest that the average FPG levels are useful predictors of all-cause mortality in dialysis patients. In addition, an increasing trend in average FPG levels indicates poor survival.

[Comparison of peritoneal dialysis and hemodialysis survival in Provence-Alpes-Côte d'Azur]

PURPOSE

To analyze and compare survival of patients initially treated with peritoneal dialysis (PD) or hemodialysis (HD).

METHODS

We used data from the French REIN registry. We included all patients aged 18 years or more who started dialysis between 1st January 2004 and 12 December 2012 in Provence-Alpes-Côte d'Azur Region (PACA). These patients were followed up until 30 June 2014. Survival curves were generated using the Kaplan-Meier technique and tested using the log-rank test. Variables predictive of all-cause mortality were determined using Cox regression models. The propensity score was used.

MAIN RESULTS

Survival was similar between initial dialysis modalities: PD and HD, even after adjusting for the propensity score. But, when we exclude the patients who had switched from one technique of dialysis to another, survival was better in HD patients. According to the multivariate analysis, advanced age and the lack of walking autonomy appear to be associated with an increase in mortality in dialysis patients. But, the presence of hypertension improve the survival in this cohort.

CONCLUSION

The survival is similar between hemodialysis and peritoneal dialysis.

Impact of dialysis modality on the survival of patients with end-stage renal disease and prior stroke

PURPOSE

Of patients with end-stage renal disease (ESRD), 8-16 % had a history of stroke at dialysis initiation. We used the National Health Insurance Research Database of Taiwan to evaluate whether peritoneal dialysis (PD) or hemodialysis (HD) confers a survival advantage for patients with incident ESRD and prior stroke.

METHODS

We identified 975 patients undergoing PD and 975 propensity score-matched patients with newly diagnosed ESRD and prior stroke undergoing HD between 2000 and 2010. Both cohorts were followed up until the end of 2011. Comparisons of the risks of mortality between PD and HD were analyzed using the Cox proportional hazards regression model.

RESULTS

In the propensity score-matched cohorts, there was a 2.4 per 100 person-years greater mortality in patients with PD (20.4 vs. 18.0 per 100 person-years) with an adjusted hazard ratio (HR) of 1.20 (95 % CI 1.06-1.36). For patients with diabetes, ESRD and prior stroke, patients undergoing PD had inferior survival compared with those undergoing HD (adjusted HR 1.22, 95 % CI 1.05-1.43), particularly among female patients (adjusted HR 1.55, 95 % CI 1.25-1.91). For patients with ESRD and prior stroke but without diabetes, there was no significant difference in mortality between PD and HD (adjusted HR 1.20, 95 % CI 0.96-1.50).

CONCLUSIONS

PD was associated with overall poorer survival among patients with diabetes, ESRD and prior stroke and with similar overall survival among patients with ESRD and prior stroke, but without diabetes, compared with HD.

Hemodialysis versus Peritoneal Dialysis: A Comparison of Survival Outcomes in South-East Asian Patients with End-Stage Renal Disease

Background

Studies comparing patient survival of hemodialysis (HD) and peritoneal dialysis (PD) have yielded conflicting results and no such study was from South-East Asia. This study aimed to compare the survival outcomes of patients with end-stage renal disease (ESRD) who started dialysis with HD and PD in Singapore.

Methods

Survival data for a maximum of 5 years from a single-center cohort of 871 ESRD patients starting dialysis with HD (n = 641) or PD (n = 230) from 2005–2010 was analyzed using the flexible Royston-Parmar (RP) model. The model was also applied to a subsample of 225 propensity-score-matched patient pairs and subgroups defined by age, diabetes mellitus, and cardiovascular disease.

Results

After adjusting for the effect of socio-demographic and clinical characteristics, the risk of death was higher in patients initiating dialysis with PD than those initiating dialysis with HD (hazard ratio [HR]: 2.08; 95% confidence interval [CI]: 1.67–2.59; p<0.001), although there was no significant difference in mortality between the two modalities in the first 12 months of treatment. Consistently, in the matched subsample, patients starting PD had a higher risk of death than those starting HD (HR: 1.73, 95% CI: 1.30–2.28, p<0.001). Subgroup analysis showed that PD may be similar to or better than HD in survival outcomes among young patients (≤65 years old) without diabetes or cardiovascular disease.

Conclusion

ESRD patients who initiated dialysis with HD experienced better survival outcomes than those who initiated dialysis with PD in Singapore, although survival outcomes may not differ between the two dialysis modalities in young and healthier patients. These findings are potentially confounded by selection bias, as patients were not randomized to the two dialysis modalities in this cohort study.

A Global Overview of the Impact of Peritoneal Dialysis First or Favored Policies: An Opinion

Given the ever-increasing burden of end-stage renal disease (ESRD) in a global milieu of limited financial and health resources, interested parties continue to search for ways to optimize dialysis access. Government and payer initiatives to increase access to renal replacement therapies (RRTs), particularly peritoneal dialysis (PD) and hemodialysis (HD), may have meaningful impacts from clinical and health-economic perspectives; and despite similar clinical and humanistic outcomes between the two dialysis modalities, PD may be the more convenient and resource-conscious option. This review assessed country-specific PD-First/Favored policies and their associated background, implementation, and outcomes. It was found that barriers to policy-implementation are broadly associated with government policy, economics, provider or healthcare professional education, modality-related factors, and patient-related factors. Notably, the success of a given country's PD-Favored policy was inversely associated with the extent of HD infrastructure. It is hoped that this review will provide a foundation across countries to share lessons learned during the development and implementation of PD-First/Favored policies.

Effect Modifying Role of Serum Calcium on Mortality-Predictability of PTH and Alkaline Phosphatase in Hemodialysis Patients: An Investigation Using Data from the Taiwan Renal Registry Data System from 2005 to 2012

Predicting mortality in dialysis patients based on low intact parathyroid hormone levels is difficult, because aluminum intoxication, malnutrition, older age, race, diabetes, or peritoneal dialysis may influence these levels. We investigated the clinical implications of low parathyroid hormone levels in relation to the mortality of dialysis patients using sensitive, stratified, and adjusted models and a nationwide dialysis database. We analyzed data from 2005 to 2012 that were held on the Taiwan Renal Registry Data System, and 94,983 hemodialysis patients with valid data regarding their intact parathyroid levels were included in this study. The patient cohort was subdivided based on the intact parathyroid hormone and alkaline phosphatase levels. The mean hemodialysis duration within this cohort was 3.5 years. The mean (standard deviation) age was 62 (14) years. After adjusting for age, sex, diabetes, the hemodialysis duration, serum albumin levels, hematocrit levels, calcium levels, phosphate levels, and the hemodialysis treatment adequacy score, the single-pool Kt/V, the crude and adjusted all-cause mortality rates increased when alkaline phosphatase levels were higher or intact parathyroid hormone levels were lower. In general, at any given level of serum calcium or phosphate, patients with low intact parathyroid hormone levels had higher mortality rates than those with normal or high iPTH levels. At a given alkaline phosphatase level, the hazard ratio for all-cause mortality was 1.33 (p < 0.01, 95% confidence interval 1.27–1.39) in the group with intact parathyroid hormone levels < 150 pg/mL and serum calcium levels > 9.5 mg/dL, but in the group with intact parathyroid hormone levels > 300 pg/mL and serum calcium levels > 9.5 mg/dL, the hazard ratio was 0.92 (95% confidence interval 0.85–1.01). Hence, maintaining albumin-corrected high serum calcium levels at > 9.5 mg/dL may correlate with poor prognoses for patients with low intact parathyroid hormone levels.

Dialysis Modality and Mortality in the Elderly: A Meta-Analysis

BACKGROUND AND OBJECTIVES

Identifying the appropriate choice between hemodialysis (HD) and peritoneal dialysis (PD) is an unresolved issue in elderly patients with ESRD, who are at high risk for death but have a low chance of receiving kidney transplantation.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Data on 13,065 incident dialysis Korean patients (age≥65 years) receiving HD (n=10,675) or PD (n=2390) were obtained from the Korean Health Insurance dataset. Multiple statistical approaches, including the multivariate Cox model, were used to compare mortality between Korean patients receiving PD and those receiving HD. Subsequently, meta-analysis of previous comparison studies (published since the year 2000; population-based studies) and the Korean dataset was performed.

RESULTS

During a mean duration of 1.8±1.3 years (maximum of 5 years), the Korean PD group had a higher mortality rate than the Korean HD group (hazard ratio [HR], 1.20 [95% confidence interval (95% CI), 1.13 to 1.28]; P<0.001 by multivariate Cox model). The discrepancy between the two modalities was greater in the presence of certain conditions, such as diabetes mellitus or longer dialysis duration. In the meta-analysis, 15 studies involving >631,421 elderly patients were reviewed. Compared with HD, the pooled HR with PD was 1.10 (95% CI, 1.01 to 1.20). When the meta-analysis was stratified by confounding factors, the survival benefit from HD was particularly strong in subgroups that had diabetes mellitus, had long dialysis duration (>1 year), or contained cohorts starting dialysis in the 1990s.

CONCLUSIONS

A meta-analysis that included results in Korean patients suggests a higher risk for death in elderly patients receiving PD than in those receiving HD.

Improving survival rate of Korean patients initiating dialysis

PURPOSE

The aim of this study was to investigate whether the survival rate among Korean dialysis patients changed during the period between 2005 and 2008 in Korea.

MATERIALS AND METHODS

A total of 32357 patients who began dialysis between January 1, 2005 and December 31, 2008 were eligible for analysis. Baseline demographics, comorbidities, and mortality data were obtained from the database of the Health Insurance Review & Assessment Service.

RESULTS

Kaplan-Meier curves according to the year of dialysis initiation showed that the survival rate was significantly different (log-rank test, p=0.005), most notably among peritoneal dialysis (PD) patients (p<0.001), although not among hemodialysis (HD) patients (p=0.497). In multivariate analysis, however, patients initiating either HD or PD in 2008 also had a significantly lower risk of mortality compared to those who began dialysis in 2005. Subgroup survival analysis among patients initiating dialysis in 2008 revealed that the survival rate of PD patients was significantly higher than that of HD patients (p=0.001), and the survival benefit of PD over HD remained in non-diabetic patients aged less than 65 years after adjustment of covariates.

CONCLUSION

Survival of Korean patients initiating dialysis from 2005 to 2008 has improved over time, particularly in PD patients. In addition, survival rates among patients initiating dialysis in 2008 were different according to patients' age and diabetes, thus we need to consider these factors when dialysis modality should be chosen.

A population-based approach indicates an overall higher patient mortality with peritoneal dialysis compared to hemodialysis in Korea

To date, only a few large-scale studies have measured the effect of dialysis modality on mortality in Asian populations. Here, we sought to compare survival between incident hemodialysis (HD) and peritoneal dialysis (PD) patients using the Korean Health Insurance Review & Assessment Service database. This enabled us to perform a population-based complete survey that included 32,280 incident dialysis patients and followed them for a median of 26.5 months. To reduce biases due to nonrandomization, we first matched 7049 patient pairs with similar propensity scores. Using the log-rank test, we found the mortality rate in PD patients was significantly higher than that in HD patients. Subsequent subgroup analyses indicated that in older patients (55 years and older), with the exception of the subgroup of patients with no comorbidities and the subgroup of patients with malignancy, PD was consistently associated with a higher mortality rate. In younger patients (under 55 years), regardless of the covariates, the survival rate of PD patients was comparable to that of HD patients. Thus, while the overall mortality rate was higher in incident PD patients, mortality rates of some incident PD and HD patients were comparable in Korea.

Survival and other clinical outcomes of maintenance hemodialysis patients in Taiwan: a 5-year multicenter follow-up study

The increasing aging and diabetes mellitus (DM) patients in dialysis population make the quality maintenance of dialysis an imperative issue. Recently, an increasing number of dialysis centers were run by private dialysis providers, many of which apply quality assurance programs and performance management systems to dialysis care. We studied patients in dialysis facilities in Taiwan run by a private chain to see clinical outcomes of centers operating under these systemic strategies. Hemodialysis patients from January 1, 2008 to December 31, 2012 in 25 dialysis facilities in Taiwan, which received the management and consultation from a dialysis service provider, NephroCare (NC), were included. Data pivotal to quality of dialysis were analyzed. During a 5-year interval, 5161 hemodialysis patients were included. For volume control, the proportion of patients with weight gain ≥4.5% decreases from 41.7% to 30.2%. Mean Kt/V is 1.74 ± 0.28. Mean albumin level is 3.92 ± 0.38 g/dL. Patients with phosphate <5.5 mg/dL is up to 71.8%. The mean hemoglobin level is 10.70 ± 1.40 g/dL. More than 80% of patients have adequate iron status. Further, 73% of patients use native arteriovenous fistula. Hospitalization-free survival rate was 56% at the fifth year. Patient survival rate at the fifth year was 66.4%. Overall clinical performances were maintained very stable in NC facilities from this temporal data analysis. The hospitalization and survival rate also compare favorably with those reported internationally. These results warrant further studies to justify the application of this kind of quality assurance programs and performance management systems in dialysis care.

Relative survival of peritoneal dialysis and haemodialysis patients: effect of cohort and mode of dialysis initiation

INTRODUCTION

Epidemiological studies consistently show an initial survival advantage for PD patients compared to HD. It has recently been suggested that this is due to the fact that many HD patients are referred late, and start dialysis on an acute, in-patient basis. The present study was performed to investigate (1) whether, and if so, how, PD and HD prognosis had changed in recent years, (2) whether a potential survival advantage of PD versus HD is constant over dialysis duration, and (3) whether differences in prognosis could be explained by patient age, renal diagnosis of diabetic nephropathy, or mode of dialysis initiation.

PATIENTS AND METHODS

12095 patients starting dialysis therapy between 1990 and 2010 in Denmark were studied. Prognosis was assessed according to initial dialysis modality on an intention-to-treat basis, censored for transplantation. Results were adjusted for age, sex, renal diagnosis, Charlson Comorbidity Index (CCI), and mode of dialysis initiation.

RESULTS

Overall adjusted prognosis improved by 34% (HD 30%, PD 42%). PD prognosis relative to HD improved, and was 16% better at the end of the period. Final PD prognosis improved consistently from 1990-99 to 2000-10 in all subgroups. PD was associated with a significant initial survival advantage, both overall and for all subgroups For the latter cohort, overall PD prognosis was better than HD for the first 4 years, after which it was insignificantly worse. The initial survival advantage was also present in a subgroup analysis of patients with early & routine ESRD initiation.

CONCLUSIONS

Dialysis survival has increased during the past 20 years. PD survival since 2000 has been better than HD, overall and for all subgroups. The difference in survival is not explained by mode of dialysis initiation.

Shorter daily dwelling time in peritoneal dialysis attenuates the epithelial-to-mesenchymal transition of mesothelial cells

Background

Peritoneal dialysis (PD) therapy is known to induce morphological and functional changes in the peritoneal membrane. Long-term exposure to conventional bio-incompatible dialysate and peritonitis is the main etiology of inflammation. Consequently, the peritoneal membrane undergoes structural changes, including angiogenesis, fibrosis, and hyalinizing vasculopathy, which ultimately results in technique failure. The epithelial-to-mesenchymal transition (EMT) of mesothelial cells (MCs) plays an important role during the above process; however, the clinical parameters associated with the EMT process of MCs remain to be explored.

Methods

To investigate the parameters impacting EMT during PD therapy, 53 clinical stable PD patients were enrolled. EMT assessments were conducted through human peritoneal MCs cultured from dialysate effluent with one consistent standard criterion (MC morphology and the expression of an epithelial marker, cytokeratin 18). The factors potentially associated with EMT were analyzed using logistic regression analysis. Primary MCs derived from the omentum were isolated for the in vitro study.

Results

Forty-seven percent of the patients presented with EMT, 28% with non-EMT, and 15% with a mixed presentation. Logistic regression analysis showed that patients who received persistent PD therapy (dwelling time of 24 h/day) had significantly higher EMT tendency. These results were consistent in vitro.

Conclusions

Dwelling time had a significant effect on the occurrence of EMT on MCs.

PD First: peritoneal dialysis as the default transition to dialysis therapy

Peritoneal dialysis (PD) and in-center hemodialysis (HD) are accepted as clinically equivalent dialysis modalities, yet in-center HD is the predominant renal replacement therapy (RRT) modality offered to new end-stage renal disease (ESRD) patients in the United States and most other industrialized nations. This predominance has little to do with clinical outcomes, patient choice, cost, or quality of life. It has been driven by ease of HD initiation, physician experience and training, inadequate pre-ESRD patient education, ample in-center HD capacity, and lack of adequate infrastructure for PD-related care. As compared with in-center HD, PD is a widely applicable, yet underutilized modality of RRT that provides comparable clinical outcomes, superior quality of life measures, significant cost savings, and many other unmeasured advantages. A "PD First" approach not only has advantages for patients but also physicians, healthcare systems, and society. In this review, we will summarize evidence demonstrating that PD should be the default modality when new ESRD patients are transitioning to dialysis therapy when preemptive transplantation is not an option and highlight the essential infrastructural requirements to allow for a "PD First" model.

Survival in dialysis patients is different between patients with diabetes as primary renal disease and patients with diabetes as a co-morbid condition

AIMS/HYPOTHESIS

A previous study in Dutch dialysis patients showed no survival difference between patients with diabetes as primary renal disease and those with diabetes as a co-morbid condition. As this was not in line with our hypothesis, we aimed to verify these results in a larger international cohort of dialysis patients.

METHODS

For the present prospective study, we used data from the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry. Incident dialysis patients with data on co-morbidities (n = 15,419) were monitored until kidney transplantation, death or end of the study period (5 years). Cox regression was performed to compare survival for patients with diabetes as primary renal disease, patients with diabetes as a co-morbid condition and non-diabetic patients.

RESULTS

Of the study population, 3,624 patients (24%) had diabetes as primary renal disease and 1,193 (11%) had diabetes as a co-morbid condition whereas the majority had no diabetes (n = 10,602). During follow-up, 7,584 (49%) patients died. In both groups of diabetic patients mortality was higher compared with the non-diabetic patients. Mortality was higher in patients with diabetes as primary renal disease than in patients with diabetes as a co-morbid condition, adjusted for age, sex, country and malignancy (HR 1.20, 95% CI 1.10, 1.30). An analysis stratified by dialysis modality yielded similar results.

CONCLUSIONS/INTERPRETATION

Overall mortality was significantly higher in patients with diabetes as primary renal disease compared with those with diabetes as a co-morbid condition. This suggests that survival in diabetic dialysis patients is affected by the extent to which diabetes has induced organ damage.

The role of peritoneal dialysis in modern renal replacement therapy

Most patients starting dialysis can choose between peritoneal dialysis and haemodialysis. There is little evidence proving that one form of dialysis is better than the other; although there may be an early advantage to peritoneal dialysis (PD) in young patients with residual function this effect is short-lived. Technique failure develops after years on PD so dialysis modality will often change during a long dialysis career. Quality of life studies, which must be interpreted carefully, indicate that patients require information about the impact of dialysis on their lifestyle as well as health-related outcomes so that they can choose the most suitable dialysis modality. Increasing numbers of frail elderly patients are starting dialysis; support in the home by nursing staff may facilitate the use of PD in this group. In the UK guidelines prioritise the patient's choice of dialysis modality (where feasible) based on good quality predialysis education. Cost of treatment is generally lower on PD, which is particularly recommended for patients with residual renal function and few comorbidities.

Modelling competing risks in nephrology research: an example in peritoneal dialysis

BACKGROUND

Modelling competing risks is an essential issue in Nephrology Research. In peritoneal dialysis studies, sometimes inappropriate methods (i.e. Kaplan-Meier method) have been used to estimate probabilities for an event of interest in the presence of competing risks. In this situation a competing risk analysis should be preferable. The objectives of this study are to describe the bias resulting from the application of standard survival analysis to estimate peritonitis-free patient survival and to provide alternative statistical approaches taking competing risks into account.

METHODS

The sample comprises patients included in a university hospital peritoneal dialysis program between October 1985 and June 2011 (n = 449). Cumulative incidence function and competing risk regression models based on cause-specific and subdistribution hazards were discussed.

RESULTS

The probability of occurrence of the first peritonitis is wrongly overestimated using Kaplan-Meier method. The cause-specific hazard model showed that factors associated with shorter time to first peritonitis were age (≥55 years) and previous treatment (haemodialysis). Taking competing risks into account in the subdistribution hazard model, age remained significant while gender (female) but not previous treatment was identified as a factor associated with a higher probability of first peritonitis event.

CONCLUSIONS

In the presence of competing risks outcomes, Kaplan-Meier estimates are biased as they overestimated the probability of the occurrence of an event of interest. Methods which take competing risks into account provide unbiased estimates of cumulative incidence for each specific outcome experienced by patients. Multivariable regression models such as those based on cause-specific hazard and on subdistribution hazard should be used in this competing risk setting.

Risk factors of short-term mortality after acute nonvariceal upper gastrointestinal bleeding in patients on dialysis: a population-based study

Background

Impaired kidney function is an established predictor of mortality after acute nonvariceal upper gastrointestinal bleeding (ANVUGIB); however, which factors are associated with mortality after ANVUGIB among patients undergoing dialysis is unknown. We examined the associations among demographic characteristics, dialysis-specific features, and comorbid conditions with short-term mortality after ANVUGIB among patients on dialysis.

Methods

Design: Retrospective cohort study. Setting: United States Renal Data System (USRDS), a nation-wide registry of patients with end-stage renal disease. Participants: All ANVUGIB episodes identified by validated algorithms in Medicare-covered patients between 2003 and 2007. Measurements: Demographic characteristics and comorbid conditions from 1 year of billing claims prior to each bleeding event. We used logistic regression extended with generalized estimating equations methods to model the associations among risk factors and 30-day mortality following ANVUGIB events.

Results

From 2003 to 2007, we identified 40,016 eligible patients with 50,497 episodes of ANVUGIB. Overall 30-day mortality was 10.7% (95% CI: 10.4-11.0). Older age, white race, longer dialysis vintage, peritoneal dialysis (vs. hemodialysis), and hospitalized (vs. outpatient) episodes were independently associated with a higher risk of 30-day mortality. Most but not all comorbid conditions were associated with death after ANVUGIB. The joint ability of all factors captured to discriminate mortality was modest (c=0.68).

Conclusions

We identified a profile of risk factors for 30-day mortality after ANVUGIB among patients on dialysis that was distinct from what had been reported in non-dialysis populations. Specifically, peritoneal dialysis and more years since initiation of dialysis were independently associated with short-term death after ANVUGIB.

Predicting mortality of incident dialysis patients in Taiwan--a longitudinal population-based study

Background

Comorbid conditions are highly prevalent among patients with end-stage renal disease (ESRD) and index score is a predictor of mortality in dialysis patients. The aim of this study is to perform a population-based cohort study to investigate the survival rate by age and Charlson comorbidity index (CCI) in incident dialysis patients.

Methods

Using the catastrophic illness registration of the Taiwan National Health Insurance Research Database for all patients from 1 January 1998 to 31 December 2008, individuals newly diagnosed with ESRD and receiving dialysis for more than 90 days were eligible for our study. Individuals younger than 18 years or renal transplantation patients either before or after dialysis were excluded. We calculated the CCI, age-weighted CCI by Deyo-Charlson method according to ICD-9 code and categorized CCI into six groups as index scores <3, 4–6, 7–9, 10–12, 13–15, >15. Cox regression models were used to analyze the association between age, CCI and survival, and the risk markers of survival.

Results

There were 79,645 incident dialysis patients, whose mean age (± SD) was 60.96 (±13.92) years; 51.43% of patients were women and 51.2% were diabetic. In cox proportional hazard models and stratifying by age, older patients had significantly higher mortality than younger patients. The mortality risk was higher in persons with higher CCI as compared with low CCI. Mortality increased steadily with higher age or comorbidity both for unadjusted and for adjusted models. For all age groups, mortality rates increased in different CCI groups with the highest rates occurring in the oldest age groups.

Conclusions

Age and CCI are both strong predictors of survival in Taiwan. The older age or higher comorbidity index in incident dialysis patient is associated with lower long-term survival rates. These population-based estimates may assist clinicians who make decisions when patients need long-term dialysis.

Prevalence and correlates of depression among chronic kidney disease patients in Taiwan

Background

Chronic kidney disease (CKD) is a progressive disease that causes a permanent impairment of renal function and premature mortality. The associated prognosis may result in serious psychological distress to the affected individual. However, there are limited data on the psychological correlates, and in particular depression, in Chinese CKD patients. This study aimed to examine the prevalence of depression, as well as the influence of other psychosocial factors on depression, among Taiwanese CKD patients.

Methods

We used a cross-sectional research design to recruit 270 CKD patients who were not undergoing dialysis treatment at a hospital in southern Taiwan during 2011. The structured questionnaire used in this study gathered information on respondent demographic and disease characteristics, and information obtained from the Taiwanese Depression Questionnaire. Factors associated with depression were examined by a multiple logistic regression analysis.

Results

The crude and age-standardized prevalence of depression were 22.6% and 20.6%, respectively. Those who had sleep disturbances, reported having no religious beliefs, followed no regular exercise regimen, and were diagnosed with stage III or above CKD demonstrated a significantly higher risk of depression.

Conclusion

Our findings are beneficial to healthcare providers, as they identify both the prevalence of depression and several of its correlates. By identifying CKD patients with a higher risk of depression, healthcare providers may be better able to ensure the provision of appropriate rehabilitation to this population.

Report of the first peritoneal dialysis program in Guyana, South America

INTRODUCTION

In 2008, we initiated the first Guyanese comprehensive kidney replacement program, comprising hemodialysis (HD), peritoneal dialysis (PD), vascular access procedures, and living-donor kidney transplantation. The government of Guyana, US-based philanthropists, US-based physicians, and Guyanese caregivers teamed up to form a public-private partnership. This pilot program was free of cost to the patients.

METHODS

From July 2010 to the time of writing, we placed 17 patients with end-stage kidney disease on PD, which was used as a bridge to living-donor kidney transplantation. During the same period, we placed 12 primary arteriovenous fistulae.

RESULTS

The 17 patients who received a PD catheter had a mean age of 43.6 years and a mean follow-up of 5.3 months. In that group, 2 deaths occurred (from multi-organ failure) within 2 weeks of catheter placement, and 2 patients were switched to HD because of inadequate clearance. Technical issues were noted in 2 patients, and 3 patients developed peritonitis (treated with intravenous antibiotics). An exit-site abscess in 1 patient was drained under local anesthesia. The peritonitis rate was 0.36 episodes per patient-year. Of the 17 patients who received PD, 4 underwent living-donor kidney transplantation.

CONCLUSIONS

In Guyana, PD is a safe and cost-effective option; it may be equally suitable for similar developing countries. In Guyana, PD was used as a bridge to living-donor kidney transplantation. We have been able to sustain this program since 2008 by making incremental gains and nurturing the ongoing public-private partnership.