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Ethier I, Hayat A, Pei J, Hawley CM, Johnson DW, Francis RS, Wong G, Craig JC, Viecelli AK, Htay H, Ng S, Leibowitz S, Cho Y. Peritoneal dialysis versus haemodialysis for people commencing dialysis. Cochrane Database Syst Rev 2024; 6:CD013800. [PMID: 38899545 PMCID: PMC11187793 DOI: 10.1002/14651858.cd013800.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
BACKGROUND Peritoneal dialysis (PD) and haemodialysis (HD) are two possible modalities for people with kidney failure commencing dialysis. Only a few randomised controlled trials (RCTs) have evaluated PD versus HD. The benefits and harms of the two modalities remain uncertain. This review includes both RCTs and non-randomised studies of interventions (NRSIs). OBJECTIVES To evaluate the benefits and harms of PD, compared to HD, in people with kidney failure initiating dialysis. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies from 2000 to June 2024 using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. MEDLINE and EMBASE were searched for NRSIs from 2000 until 28 March 2023. SELECTION CRITERIA RCTs and NRSIs evaluating PD compared to HD in people initiating dialysis were eligible. DATA COLLECTION AND ANALYSIS Two investigators independently assessed if the studies were eligible and then extracted data. Risk of bias was assessed using standard Cochrane methods, and relevant outcomes were extracted for each report. The primary outcome was residual kidney function (RKF). Secondary outcomes included all-cause, cardiovascular and infection-related death, infection, cardiovascular disease, hospitalisation, technique survival, life participation and fatigue. MAIN RESULTS A total of 153 reports of 84 studies (2 RCTs, 82 NRSIs) were included. Studies varied widely in design (small single-centre studies to international registry analyses) and in the included populations (broad inclusion criteria versus restricted to more specific participants). Additionally, treatment delivery (e.g. automated versus continuous ambulatory PD, HD with catheter versus arteriovenous fistula or graft, in-centre versus home HD) and duration of follow-up varied widely. The two included RCTs were deemed to be at high risk of bias in terms of blinding participants and personnel and blinding outcome assessment for outcomes pertaining to quality of life. However, most other criteria were assessed as low risk of bias for both studies. Although the risk of bias (Newcastle-Ottawa Scale) was generally low for most NRSIs, studies were at risk of selection bias and residual confounding due to the constraints of the observational study design. In children, there may be little or no difference between HD and PD on all-cause death (6 studies, 5752 participants: RR 0.81, 95% CI 0.62 to 1.07; I2 = 28%; low certainty) and cardiovascular death (3 studies, 7073 participants: RR 1.23, 95% CI 0.58 to 2.59; I2 = 29%; low certainty), and was unclear for infection-related death (4 studies, 7451 participants: RR 0.98, 95% CI 0.39 to 2.46; I2 = 56%; very low certainty). In adults, compared with HD, PD had an uncertain effect on RKF (mL/min/1.73 m2) at six months (2 studies, 146 participants: MD 0.90, 95% CI 0.23 to 3.60; I2 = 82%; very low certainty), 12 months (3 studies, 606 participants: MD 1.21, 95% CI -0.01 to 2.43; I2 = 81%; very low certainty) and 24 months (3 studies, 334 participants: MD 0.71, 95% CI -0.02 to 1.48; I2 = 72%; very low certainty). PD had uncertain effects on residual urine volume at 12 months (3 studies, 253 participants: MD 344.10 mL/day, 95% CI 168.70 to 519.49; I2 = 69%; very low certainty). PD may reduce the risk of RKF loss (3 studies, 2834 participants: RR 0.55, 95% CI 0.44 to 0.68; I2 = 17%; low certainty). Compared with HD, PD had uncertain effects on all-cause death (42 studies, 700,093 participants: RR 0.87, 95% CI 0.77 to 0.98; I2 = 99%; very low certainty). In an analysis restricted to RCTs, PD may reduce the risk of all-cause death (2 studies, 1120 participants: RR 0.53, 95% CI 0.32 to 0.86; I2 = 0%; moderate certainty). PD had uncertain effects on both cardiovascular (21 studies, 68,492 participants: RR 0.96, 95% CI 0.78 to 1.19; I2 = 92%) and infection-related death (17 studies, 116,333 participants: RR 0.90, 95% CI 0.57 to 1.42; I2 = 98%) (both very low certainty). Compared with HD, PD had uncertain effects on the number of patients experiencing bacteraemia/bloodstream infection (2 studies, 2582 participants: RR 0.34, 95% CI 0.10 to 1.18; I2 = 68%) and the number of patients experiencing infection episodes (3 studies, 277 participants: RR 1.23, 95% CI 0.93 to 1.62; I2 = 20%) (both very low certainty). PD may reduce the number of bacteraemia/bloodstream infection episodes (2 studies, 2637 participants: RR 0.44, 95% CI 0.27 to 0.71; I2 = 24%; low certainty). Compared with HD; It is uncertain whether PD reduces the risk of acute myocardial infarction (4 studies, 110,850 participants: RR 0.90, 95% CI 0.74 to 1.10; I2 = 55%), coronary artery disease (3 studies, 5826 participants: RR 0.95, 95% CI 0.46 to 1.97; I2 = 62%); ischaemic heart disease (2 studies, 58,374 participants: RR 0.86, 95% CI 0.57 to 1.28; I2 = 95%), congestive heart failure (3 studies, 49,511 participants: RR 1.10, 95% CI 0.54 to 2.21; I2 = 89%) and stroke (4 studies, 102,542 participants: RR 0.94, 95% CI 0.90 to 0.99; I2 = 0%) because of low to very low certainty evidence. Compared with HD, PD had uncertain effects on the number of patients experiencing hospitalisation (4 studies, 3282 participants: RR 0.90, 95% CI 0.62 to 1.30; I2 = 97%) and all-cause hospitalisation events (4 studies, 42,582 participants: RR 1.02, 95% CI 0.81 to 1.29; I2 = 91%) (very low certainty). None of the included studies reported specifically on life participation or fatigue. However, two studies evaluated employment. Compared with HD, PD had uncertain effects on employment at one year (2 studies, 593 participants: RR 0.83, 95% CI 0.20 to 3.43; I2 = 97%; very low certainty). AUTHORS' CONCLUSIONS The comparative effectiveness of PD and HD on the preservation of RKF, all-cause and cause-specific death risk, the incidence of bacteraemia, other vascular complications (e.g. stroke, cardiovascular events) and patient-reported outcomes (e.g. life participation and fatigue) are uncertain, based on data obtained mostly from NRSIs, as only two RCTs were included.
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Affiliation(s)
- Isabelle Ethier
- Department of Nephrology, Centre hospitalier de l'Université de Montréal, Montréal, Canada
- Health innovation and evaluation hub, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Ashik Hayat
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Juan Pei
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Department of Nephrology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Carmel M Hawley
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - Ross S Francis
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Germaine Wong
- School of Public Health, The University of Sydney, Sydney, Australia
| | - Jonathan C Craig
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Andrea K Viecelli
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - Htay Htay
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Samantha Ng
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
| | - Saskia Leibowitz
- Department of Nephrology, Logan Hospital, Meadowbrook, Australia
| | - Yeoungjee Cho
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
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2
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Kim YH, Kim Y, Ha N, Cho JH, Kim YS, Kang SW, Kim NH, Yang CW, Kim YL, Lee JP, Lee W, Oh HJ. The effect of dialysis modality on annual mortality: A prospective cohort study. Sci Rep 2024; 14:14035. [PMID: 38890469 PMCID: PMC11189506 DOI: 10.1038/s41598-024-64914-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 06/14/2024] [Indexed: 06/20/2024] Open
Abstract
Despite numerous studies on the effect of each dialysis modality on mortality, the issue remains controversial. We investigated the hazard rate of mortality in patients with incident end-stage renal disease (ESRD) concerning initial dialysis modality (hemodialysis vs. peritoneal dialysis). Using a nationwide, multicenter, prospective cohort in South Korea, we studied 2207 patients, of which 1647 (74.6%) underwent hemodialysis. We employed the weighted Fine and Gray model over the follow-up period using inverse probability of treatment and censoring weighting. Landmark analysis was used for identifying the changing effect of dialysis modality on individuals who remained event-free at each landmark point. No significant difference in hazard rate was observed overall. However, the peritoneal dialysis group had a significantly higher hazard rate than the hemodialysis group among patients under 65 years after 4- and 5- year follow-up. A similar pattern was observed among those with diabetes mellitus. Landmark analysis also showed the higher hazard rate for peritoneal dialysis at 2 years for the education-others group and at 3 years for the married group. These findings may inform dialysis modality decisions, suggesting a preference for hemodialysis in young patients with diabetes, especially for follow-ups longer than 3 years.
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Affiliation(s)
- Yae Hyun Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yeonjin Kim
- Department of Public Health Sciences, Graduate School of Public Health, Seoul National University, Seoul, Republic of Korea
| | - Nayoung Ha
- Department of Public Health Sciences, Graduate School of Public Health, Seoul National University, Seoul, Republic of Korea
| | - Jang-Hee Cho
- Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Shin-Wook Kang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Nam-Ho Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Chul Woo Yang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea Seoul St Mary's Hospital, Seoul, Republic of Korea
| | - Yong-Lim Kim
- Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Jung Pyo Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Woojoo Lee
- Department of Public Health Sciences, Graduate School of Public Health, Seoul National University, Seoul, Republic of Korea.
| | - Hyung Jung Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.
- Department of Nephrology, Sheikh Khalifa Specialty Hospital, Ras Al Khaimah, United Arab Emirates.
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3
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Oliver MJ, Abra G, Béchade C, Brown EA, Sanchez-Escuredo A, Johnson DW, Guedes AM, Graham J, Fernandes N, Jha V, Kabbali N, Knananjubach T, Kam-Tao Li P, Lundström UH, Salenger P, Lobbedez T. Assisted peritoneal dialysis: Position paper for the ISPD. Perit Dial Int 2024; 44:160-170. [PMID: 38712887 DOI: 10.1177/08968608241246447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2024] Open
Affiliation(s)
- Matthew J Oliver
- Division of Nephrology, Department of Medicine, University of Toronto, ON, Canada
| | - Graham Abra
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Clémence Béchade
- Université Caen Normandie - UFR de Médecine, CAEN CEDEX, France
- Néphrologie, CHU CAEN, Avenue de la Côte de Nacre, Normandie Université, CAEN CEDEX, France
- ANTICIPE U1086 INSERM-UCN, Centre François Baclesse, Caen, France
| | - Edwina A Brown
- Imperial College Kidney and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK
| | | | - David W Johnson
- Department of Kidney and Transplant Services, University of Queensland at Princess Alexandra Hospital, Brisbane, QLD, Australia
| | | | | | - Natalia Fernandes
- Department of Nephrology, Juiz de Fora University Hospital, Juiz de Fora, Minas Gerais, Brazil
| | - Vivekanand Jha
- George Institute for Global Health, UNSW, New Delhi, India
- School of Public Health, Imperial College, London, UK
- Manipal Academy of Higher Education, Manipal, India
| | - Nadia Kabbali
- Nephrology Department, Hassan II University Hospital, Fez, Morocco
| | - Talerngsak Knananjubach
- Division of Nephrology, Department of Medicine and Center of Excellence in Kidney Metabolic Disorders, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Philip Kam-Tao Li
- Carol and Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Ulrika Hahn Lundström
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | | | - Thierry Lobbedez
- Université Caen Normandie - UFR de Médecine, CAEN CEDEX, France
- Néphrologie, CHU CAEN, Avenue de la Côte de Nacre, Normandie Université, CAEN CEDEX, France
- ANTICIPE U1086 INSERM-UCN, Centre François Baclesse, Caen, France
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4
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Qureshi MA, Maierean S, Crabtree JH, Clarke A, Armstrong S, Fissell R, Jain AK, Jassal SV, Hu SL, Kennealey P, Liebman S, McCormick B, Momciu B, Pauly RP, Pellegrino B, Perl J, Pirkle JL, Plumb TJ, Seshasai R, Shah A, Shah N, Shen J, Singh G, Tennankore K, Uribarri J, Vasilevsky M, Yang R, Quinn RR, Nadler A, Oliver MJ. The Association of Intra-Abdominal Adhesions with Peritoneal Dialysis Catheter-Related Complications. Clin J Am Soc Nephrol 2024; 19:472-482. [PMID: 38190176 PMCID: PMC11020425 DOI: 10.2215/cjn.0000000000000404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/21/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND This study investigated the association of intra-abdominal adhesions with the risk of peritoneal dialysis (PD) catheter complications. METHODS Individuals undergoing laparoscopic PD catheter insertion were prospectively enrolled from eight centers in Canada and the United States. Patients were grouped based on the presence of adhesions observed during catheter insertion. The primary outcome was the composite of PD never starting, termination of PD, or the need for an invasive procedure caused by flow restriction or abdominal pain. RESULTS Seven hundred and fifty-eight individuals were enrolled, of whom 201 (27%) had adhesions during laparoscopic PD catheter insertion. The risk of the primary outcome occurred in 35 (17%) in the adhesion group compared with 58 (10%) in the no adhesion group (adjusted HR, 1.64; 95% confidence interval [CI], 1.05 to 2.55) within 6 months of insertion. Lower abdominal or pelvic adhesions had an adjusted HR of 1.80 (95% CI, 1.09 to 2.98) compared with the no adhesion group. Invasive procedures were required in 26 (13%) and 47 (8%) of the adhesion and no adhesion groups, respectively (unadjusted HR, 1.60: 95% CI, 1.04 to 2.47) within 6 months of insertion. The adjusted odds ratio for adhesions for women was 1.65 (95% CI, 1.12 to 2.41), for body mass index per 5 kg/m 2 was 1.16 (95% CI, 1.003 to 1.34), and for prior abdominal surgery was 8.34 (95% CI, 5.5 to 12.34). Common abnormalities found during invasive procedures included PD catheter tip migration, occlusion of the lumen with fibrin, omental wrapping, adherence to the bowel, and the development of new adhesions. CONCLUSIONS People with intra-abdominal adhesions undergoing PD catheter insertion were at higher risk for abdominal pain or flow restriction preventing PD from starting, PD termination, or requiring an invasive procedure. However, most patients, with or without adhesions, did not experience complications, and most complications did not lead to the termination of PD therapy.
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Affiliation(s)
- Mohammad Azfar Qureshi
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Serban Maierean
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - John H. Crabtree
- Division of Nephrology and Hypertension, Harbor-University of California Los Angeles Medical Center, Torrance, California
| | - Alix Clarke
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sean Armstrong
- College of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rachel Fissell
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Arsh K. Jain
- Department of Medicine, Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Sarbjit V. Jassal
- Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Susie L. Hu
- Department of Internal Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Peter Kennealey
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Scott Liebman
- Department of Medicine, Division of Nephrology, University of Rochester, Rochester, New York
| | - Brendan McCormick
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Bogdan Momciu
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Robert P. Pauly
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Beth Pellegrino
- Division of Nephrology, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Jeffrey Perl
- Division of Nephrology, Division of Nephrology St. Michael's Hospital, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - James L. Pirkle
- Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Troy J. Plumb
- Division of Nephrology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Rebecca Seshasai
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ankur Shah
- Department of Internal Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Nikhil Shah
- Faculty of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
| | - Jenny Shen
- The Lundquist Institute at Harbor-UCLA Medical Center, Los Angeles, California
| | | | - Karthik Tennankore
- Division of Nephrology, Department of Medicine, Dalhousie University and Nova Scotia Health, Halifax, Nova Scotia, Canada
| | - Jaime Uribarri
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Murray Vasilevsky
- Division of Nephrology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Robert Yang
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Robert R. Quinn
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ashlie Nadler
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Matthew J. Oliver
- Department of Medicine, Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
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5
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Quinn RR, Oliver MJ, Clarke A, Mohamed F, Klarenbach SW, Manns BJ, Fox DE, Scott-Douglas N, Morrin L, Kozinski A, Schwartz T, Pauly R. The impact of the Starting dialysis on Time, At home on the Right Therapy (START) project on the use of peritoneal dialysis. Perit Dial Int 2024:8968608231225013. [PMID: 38379281 DOI: 10.1177/08968608231225013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND Peritoneal dialysis (PD) is actively promoted, but increasing PD utilisation is difficult. The objective of this study was to determine if the Starting dialysis on Time, At Home, on the Right Therapy (START) project was associated with an increase in the proportion of dialysis patients receiving PD within 6 months of starting therapy. METHODS Consecutive patients over age 18, with end-stage kidney failure, who started dialysis between 1 April 2015 and 31 March 2018 in the province of Alberta, Canada. Programmes were provided with high-quality data about the individual steps in the process of care that drive PD utilisation that were used to identify problem areas, design and implement interventions to address them, and then evaluate whether those interventions had impact. The primary outcome was the proportion of patients receiving PD within 6 months of starting dialysis. Secondary outcomes included hospitalisation, death or probability of transfer to haemodialysis (HD). Interrupted time series methodology was used to evaluate the impact of the quality improvement initiative on the primary and secondary outcomes. RESULTS A total of 1962 patients started dialysis during the study period. Twenty-seven per cent of incident patients received PD at baseline, and there was a 5.4% (95% confidence interval: 1.5-9.2) increase in the use of PD in the province immediately after implementation. There were no changes in the rates of hospitalisation, death or probability of transfer to HD after the introduction of START. CONCLUSIONS The approach used in the START project was associated with an increase in the use of PD in a setting with high baseline utilisation.
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Affiliation(s)
- Robert R Quinn
- Departments of Medicine & Community Health Sciences, University of Calgary, AB, Canada
| | - Matthew J Oliver
- Division of Nephrology, Department of Medicine, University of Toronto, ON, Canada
| | - Alix Clarke
- Departments of Medicine & Community Health Sciences, University of Calgary, AB, Canada
| | | | | | - Braden J Manns
- Departments of Medicine & Community Health Sciences, University of Calgary, AB, Canada
| | - Danielle E Fox
- Departments of Medicine & Community Health Sciences, University of Calgary, AB, Canada
| | - Nairne Scott-Douglas
- Departments of Medicine & Community Health Sciences, University of Calgary, AB, Canada
| | | | | | | | - Robert Pauly
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
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6
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Desbiens LC, Tennankore KK, Goupil R, Perl J, Trinh E, Chan CT, Nadeau-Fredette AC. Outcomes of Integrated Home Dialysis Care: Results From the Canadian Organ Replacement Register. Am J Kidney Dis 2024; 83:47-57.e1. [PMID: 37657633 DOI: 10.1053/j.ajkd.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 05/15/2023] [Accepted: 05/24/2023] [Indexed: 09/03/2023]
Abstract
RATIONALE & OBJECTIVE The integrated home dialysis model proposes the initiation of kidney replacement therapy (KRT) with peritoneal dialysis (PD) and a timely transition to home hemodialysis (HHD) after PD ends. We compared the outcomes of patients transitioning from PD to HHD with those initiating KRT with HHD. STUDY DESIGN Observational analysis of the Canadian Organ Replacement Register (CORR). SETTINGS & PARTICIPANTS All patients who initiated PD or HHD within the first 90 days of KRT between 2005 and 2018. EXPOSURE Patients transitioning from PD to HHD (PD+HHD group) versus patients initiating KRT with HHD (HHD group). OUTCOME (1) A composite of all-cause mortality and modality transfer (to in-center hemodialysis or PD for 90 days) and (2) all hospitalizations (considered as recurrent events). ANALYTICAL APPROACH A propensity score analysis for which PD+HHD patients were matched 1:1 to (1) incident HHD patients ("incident-match" analysis) or (2) HHD patients with a KRT vintage at least equivalent to the vintage of PD+HHD patients at the transition time ("vintage-matched" analysis). Cause-specific hazards models (composite outcome) and shared frailty models (hospitalization) were used to compare groups. RESULTS Among 63,327 individuals in the CORR, 163 PD+HHD patients (median of 1.9 years in PD) and 711 HHD patients were identified. In the incident-match analysis, compared to the HHD patients, the PD+HHD group had a similar risk of the composite outcome (HR, 0.88 [95% CI, 0.58-1.32]) and hospitalizations (HR, 1.04 [95% CI, 0.76-1.41]). In the vintage-match analysis, PD+HHD patients had a lower hazard for the composite outcome (HR, 0.61 [95% CI, 0.40-0.94]) but a similar hospitalization risk (HR, 0.85 [95% CI, 0.59-1.24]). LIMITATIONS Risk of survivor bias in the PD+HHD cohort and residual confounding. CONCLUSIONS Controlling for KRT vintage, the patients transitioning from PD to HHD had better clinical outcomes than the incident HHD patients. These data support the use of integrated home dialysis for patients initiating home-based KRT. PLAIN-LANGUAGE SUMMARY The integrated home dialysis model proposes the initiation of dialysis with peritoneal dialysis (PD) and subsequent transition to home hemodialysis (HHD) once PD is no longer feasible. It allows patients to benefit from initial lifestyle advantages of PD and to continue home-based treatments after its termination. However, some patients may prefer to initiate dialysis with HHD from the outset. In this study, we compared the long-term clinical outcomes of both approaches using a large Canadian dialysis register. We found that both options led to a similar risk of hospitalization. In contrast, the PD-to-HHD model led to improved survival when controlling for the duration of kidney failure.
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Affiliation(s)
- Louis-Charles Desbiens
- Department of Medicine, Université de Montréal, Quebec, Montreal; Hôpital Maisonneuve-Rosemont, Quebec, Montreal
| | | | - Rémi Goupil
- Department of Medicine, Université de Montréal, Quebec, Montreal; Hôpital du Sacré-Coeur de Montréal, Quebec, Montreal
| | - Jeffrey Perl
- St. Michael's Hospital, Toronto, Ontario, Canada
| | - Emilie Trinh
- McGill University Health Center, Quebec, Montreal
| | - Christopher T Chan
- Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Annie-Claire Nadeau-Fredette
- Department of Medicine, Université de Montréal, Quebec, Montreal; Hôpital Maisonneuve-Rosemont, Quebec, Montreal.
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7
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Zhou Y, Frampton C, Dowsey M, Choong P, Schilling C, Hirner M. Assessing the Mortality Rate After Primary Total Knee Arthroplasty: An Observational Study to Inform Future Economic Analysis. J Arthroplasty 2023; 38:2328-2335.e3. [PMID: 37279845 DOI: 10.1016/j.arth.2023.05.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 05/20/2023] [Accepted: 05/24/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND Previous research has focused on the perioperative or short-term (<1 year) mortality rate of total knee arthroplasty (TKA), leaving the long-term (>1 year) mortality rate unresolved. In this study, we calculated the mortality rate up to 15 years after primary TKA. METHODS Data from the New Zealand Joint Registry from April 1998 to December 2021 were analyzed. Patients aged 45 years or older who underwent TKA for osteoarthritis were included. Mortality data were linked with national records from births, deaths, and marriages. To determine the expected mortality rates in the general population, age-sex-specific life tables from statistics New Zealand were used. Mortality rate was presented as standardized mortality ratios (SMRs) - a comparison of relative mortality rate between the TKA and general populations. In total, 98,156 patients with a median follow-up of 7.25 years (range, 0.00 to 23.74) were included. RESULTS Over the entire follow-up period, 22,938 patients (23.4%) had died. The overall SMR for the TKA cohort was 1.08 (95% confidence interval (CI): 1.06 to 1.09), suggesting that TKA patients have an 8% higher mortality rate compared to the general population. However, a reduction in short-term mortality rate was observed for TKA patients up to 5 years post TKA (SMR 5 years post TKA; 0.59 95% CI: 0.57 to 0.60]). On the contrary, a significantly increased long-term mortality rate was observed in TKA patients with greater than 11 years of follow-up, particularly in men over the age of 75 years (SMR 11 to 15 years post TKA for males ≥ 75 years; 3.13 [95% CI: 2.95 to 3.31]). CONCLUSION The results suggest a reduction in short-term mortality rate for patients who undergo primary TKA. However, there is an increased long-term mortality rate particularly in men over the age of 75 years. Importantly, the mortality rates observed in this study cannot be causally attributed to TKA alone.
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Affiliation(s)
- Yushy Zhou
- Department of Surgery, The University of Melbourne, Melbourne, Australia, Fitzroy, Victoria, Australia; Department of Orthopaedic Surgery, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - Chris Frampton
- Department of Medicine, The University of Otago, Christchurch, New Zealand
| | - Michelle Dowsey
- Department of Surgery, The University of Melbourne, Melbourne, Australia, Fitzroy, Victoria, Australia
| | - Peter Choong
- Department of Surgery, The University of Melbourne, Melbourne, Australia, Fitzroy, Victoria, Australia
| | - Chris Schilling
- Department of Surgery, The University of Melbourne, Melbourne, Australia, Fitzroy, Victoria, Australia
| | - Marc Hirner
- Department of Orthopaedic Surgery, Whangarei Hospital, Whangarei, New Zealand
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8
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Quinn RR, Lam NN. Home Dialysis in North America: The Current State. Clin J Am Soc Nephrol 2023; 18:1351-1358. [PMID: 37523194 PMCID: PMC10578635 DOI: 10.2215/cjn.0000000000000273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 07/21/2023] [Indexed: 08/01/2023]
Abstract
There is widespread interest in expanding the uptake of home dialysis in North America. Although kidney transplantation should be the preferred option in eligible patients, home hemodialysis (HD) and peritoneal dialysis (PD) offer cost-effective options for KRT. In this review, the motivation for promoting home dialysis is presented, and the literature supporting it is critically reviewed. Randomized comparisons of home HD and PD with in-center HD have been challenging to conduct and provide only limited information. Nonrandomized studies are heterogeneous in their design and have often yielded conflicting results. They are prone to bias, and this must be carefully considered when evaluating this literature. Home modalities seem to have equivalent clinical outcomes and quality of life when compared with in-center HD. However, the cost of providing home therapies, particularly PD, is lower than conventional, in-center HD. Measures of home dialysis utilization, the philosophy behind their measurement, and important factors to consider when interpreting them are discussed. The importance of understanding measures of home dialysis utilization in the context of rates of kidney failure, the proportion of individuals who opt for conservative care, and rates of kidney transplantation is highlighted, and a framework for proposing targets is presented, using PD as an example.
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Affiliation(s)
- Robert R Quinn
- Cumming School of Medicine , University of Calgary , Calgary, Canada, and
- Department of Community Health Sciences , University of Calgary , Calgary, Canada
| | - Ngan N Lam
- Cumming School of Medicine , University of Calgary , Calgary, Canada, and
- Department of Community Health Sciences , University of Calgary , Calgary, Canada
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9
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Hirsch D, Lau B, Kushwaha V, Yong K. The Controversies of Coronary Artery Disease in End-Stage Kidney Disease Patients: A Narrative Review. Rev Cardiovasc Med 2023; 24:181. [PMID: 39077541 PMCID: PMC11264163 DOI: 10.31083/j.rcm2406181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/15/2023] [Accepted: 03/22/2023] [Indexed: 07/31/2024] Open
Abstract
Cardiovascular disease (CVD) accounts for more than 50% of deaths among patients with end-stage kidney disease (ESKD). Approximately 40-50% of ESKD patients have clinically significant coronary artery disease (CAD) due to atherosclerosis which accounts for a significant proportion of CVD risk. However, other CVD pathologies including myocardial fibrosis, vascular calcification and arterial stiffening play important contributory roles. The pathophysiology of CAD in ESKD is distinct from the general population. ESKD patients is typically have diffuse multi-vessel involvement with increased calcification that involves both intimal and medial layers of the arterial wall. There is a complex interplay between an increased burden of traditional Framingham risk factors and exposure to non-traditional risk factors including chronic inflammation and dialysis per se. Established treatments for CAD risk factors including cholesterol lowering with statin therapy have attenuated effects and ESKD patients also have worse outcomes after revascularisation. Recent trials such as the Canakinumab Anti-Inflammatory Thrombosis Outcomes Study (CANTOS) have established that direct modulation of inflammation improves CVD outcomes in the general population, which may prove to be a potential attractive therapeutic target in ESKD patients. Multiple retrospective observational studies comparing mortality outcomes between haemodialysis (HD) and peritoneal dialysis (PD) patients have been inconclusive. Randomised trials on this issue of clinical equipoise are clearly warranted but are unlikely to be feasible. Screening for stable CAD in asymptomatic ESKD patients remains a clinical dilemma which is unique to chronic dialysis patients being assessed for kidney transplantation. This has become particularly relevant in light of the recent ISCHEMIA-CKD trial which demonstrated no difference between optimal medical therapy and revascularisation upon CVD outcomes or mortality. The optimal strategy for screening is currently being investigated in the ongoing large international multi-centre CARSK trial. Here we discuss the pathophysiology, risk modification, treatment, screening and future directions of CAD in ESKD.
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Affiliation(s)
- Daniel Hirsch
- Department of Nephrology, Prince of Wales Hospital, Randwick, NSW 2031, Australia
- Prince of Wales Clinical School, University of New South Wales, Kensington, NSW 2033, Australia
| | - Brandon Lau
- Prince of Wales Clinical School, University of New South Wales, Kensington, NSW 2033, Australia
| | - Virag Kushwaha
- Prince of Wales Clinical School, University of New South Wales, Kensington, NSW 2033, Australia
- Department of Cardiology, Prince of Wales Hospital, Randwick, NSW 2031, Australia
| | - Kenneth Yong
- Department of Nephrology, Prince of Wales Hospital, Randwick, NSW 2031, Australia
- Prince of Wales Clinical School, University of New South Wales, Kensington, NSW 2033, Australia
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10
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Assanatham M, Pattanaprateep O, Chuasuwan A, Vareesangthip K, Supasyndh O, Lumpaopong A, Susantitaphong P, Limkunakul C, Ponthongmak W, Chaiyakittisopon K, Thakkinstian A, Ingsathit A. Economic evaluation of peritoneal dialysis and hemodialysis in Thai population with End-stage Kidney Disease. BMC Health Serv Res 2022; 22:1384. [PMID: 36411422 PMCID: PMC9677653 DOI: 10.1186/s12913-022-08827-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 11/10/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND This study aimed to conduct a cost-utility analysis of the "Peritoneal Dialysis (PD)-First" policy in 2008 under a universal health coverage scheme and hemodialysis (HD) in Thai patients with End-stage Kidney Disease (ESKD) using updated real-practice data. METHODS Markov model was used to evaluate the cost-utility of two modalities, stratified into five age groups based on the first modality taken at 20, 30, 40, 50, and 60 years old from government and societal perspectives. Input parameters related to clinical aspects and cost were obtained from 15 hospitals throughout Thailand and Thai Renal Replacement Therapy databases. Both costs and outcomes were discounted at 3%, adjusted to 2021, and converted to USD (1 USD = 33.57 Thai Baht). One-way analysis and probabilistic sensitivity analysis were performed to assess the uncertainty surrounding model parameters. RESULTS From the government perspective, compared to PD-first policy, the incremental cost-effectiveness ratio (ICER) was between 19,434 and 23,796 USD per QALY. Conversely, from a societal perspective, the ICER was between 31,913 and 39,912 USD per QALY. Both are higher than the willingness to pay threshold of 4,766 USD per QALY. CONCLUSION By applying the updated real-practice data, PD-first policy still remains more cost-effective than HD-first policy at the current willingness to pay. However, HD gained more quality-adjusted life years than PD. This information will assist clinicians and policymakers in determining the future direction of dialysis modality selection and kidney replacement therapy reimbursement policies for ESKD patients.
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Affiliation(s)
- Montira Assanatham
- grid.10223.320000 0004 1937 0490Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, 10400 Bangkok, Thailand ,grid.10223.320000 0004 1937 0490Division of Nephrology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Oraluck Pattanaprateep
- grid.10223.320000 0004 1937 0490Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road., Ratchathewi, Bangkok, Thailand
| | - Anan Chuasuwan
- grid.414501.50000 0004 0617 6015Nephrology Division, Department of Medicine, Bhumibol Adulyadej Hospital, 10220 Bangkok, Thailand
| | - Kriengsak Vareesangthip
- grid.10223.320000 0004 1937 0490Renal Division, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ouppatham Supasyndh
- grid.414965.b0000 0004 0576 1212Division of Nephrology, Department of Medicine, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| | - Adisorn Lumpaopong
- grid.414965.b0000 0004 0576 1212Pediatric Nephrology Division, Department of Pediatrics, Phramongkutklao Hospital, Bangkok, Thailand
| | - Paweena Susantitaphong
- grid.7922.e0000 0001 0244 7875Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | - Chutatip Limkunakul
- grid.412739.a0000 0000 9006 7188Division of Nephrology, Panyananthaphikkhu Chonprathan Medical Center, Srinakharinwirot University, Bangkok, Thailand
| | - Wanchana Ponthongmak
- grid.10223.320000 0004 1937 0490Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road., Ratchathewi, Bangkok, Thailand
| | - Kamolpat Chaiyakittisopon
- grid.412620.30000 0001 2223 9723Department of Community Pharmacy, Faculty of Pharmacy, Silpakorn University, Nakorn Pathom, Thailand
| | - Ammarin Thakkinstian
- grid.10223.320000 0004 1937 0490Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road., Ratchathewi, Bangkok, Thailand
| | - Atiporn Ingsathit
- grid.10223.320000 0004 1937 0490Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road., Ratchathewi, Bangkok, Thailand
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11
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Effect of Dialysis Modalities on All-Cause Mortality and Cardiovascular Mortality in End-Stage Kidney Disease: A Taiwan Renal Registry Data System (TWRDS) 2005-2012 Study. J Pers Med 2022; 12:jpm12101715. [PMID: 36294854 PMCID: PMC9605117 DOI: 10.3390/jpm12101715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 10/03/2022] [Accepted: 10/06/2022] [Indexed: 12/12/2022] Open
Abstract
Introduction: End-stage kidney disease (ESKD) patients who need renal replacement therapy need to face a dialysis modality decision: the choice between hemodialysis (HD) and peritoneal dialysis (PD). Although the global differences in HD/PD penetration are affected by health-care policies, these two modalities may exert different effects on survival in patients with ESKD. Although Taiwan did not implicate PD as first policy, we still need to compare patients’ outcomes using two modalities in a nation-wise database to determine future patients’ care and health policies. Methods: We used the nationwide Taiwan Renal Registry Data System (TWRDS) database from 2005 to 2012 and included 52,900 patients (48,371 on HD and 4529 on PD) to determine all-cause and cardiovascular mortality among ESKD patients. Results: Age-matched survival probability from all-cause mortality was significantly lower in patients on PD than in those on HD (p < 0.05). The adjusted hazard ratios of 3-year and 5-year all-cause and cardiovascular mortality were significantly higher in PD compared with HD. The presence of comorbid conditions including myocardial infarction, coronary artery disease (CAD), diabetes mellitus (DM), hypoalbuminemia, hyperferritinemia and hypophosphatemia was related with significantly higher all-cause and CV mortality in PD patients. No significant difference was noted among younger patients <45 years of age regardless of DM and/or comorbid conditions. Conclusion: Although PD did not have the survival advantage compared to HD in all dialysis populations, PD was related with superior survival in younger non-DM patients, regardless of the presence of comorbidities. Similarly, for younger ESKD patients without the risk of CV disease, both PD and HD would be suitable dialysis modalities.
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12
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Heaf J, Heiro M, Petersons A, Vernere B, Povlsen JV, Sørensen AB, Clyne N, Bumblyte I, Zilinskiene A, Randers E, Løkkegaard N, Rosenberg M, Kjellevold S, Kampmann JD, Rogland B, Lagreid I, Heimburger O, Qureshi AR, Lindholm B. First-year mortality in incident dialysis patients: results of the Peridialysis study. BMC Nephrol 2022; 23:229. [PMID: 35761193 PMCID: PMC9235232 DOI: 10.1186/s12882-022-02852-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/08/2022] [Indexed: 11/13/2022] Open
Abstract
Background Controversy surrounds which factors are important for predicting early mortality after dialysis initiation (DI). We investigated associations of predialysis course and circumstances affecting planning and execution of DI with mortality following DI. Methods Among 1580 patients participating in the Peridialysis study, a study of causes and timing of DI, we registered features of predialysis course, clinical and biochemical data at DI, incidence of unplanned suboptimal DI, contraindications to peritoneal dialysis (PD) or hemodialysis (HD), and modality preference, actual choice, and cause of modality choice. Patients were followed for 12 months or until transplantation. A flexible parametric model was used to identify independent factors associated with all-cause mortality. Results First-year mortality was 19.33%. Independent factors predicting death were high age, comorbidity, clinical contraindications to PD or HD, suboptimal DI, high eGFR, low serum albumin, hyperphosphatemia, high C-reactive protein, signs of overhydration and cerebral symptoms at DI. Among 1061 (67.2%) patients who could select dialysis modality based on personal choice, 654 (61.6%) chose PD, 368 (34.7%) center HD and 39 (3.7%) home HD. The 12-months survival did not differ significantly between patients receiving PD and in-center HD. Conclusions First-year mortality in incident dialysis patients was in addition to high age and comorbidity, associated with clinical contraindications to PD or HD, clinical symptoms, hyperphosphatemia, inflammation, and suboptimal DI. In patients with a “free” choice of dialysis modality based on their personal preferences, PD and in-center HD led to broadly similar short-term outcomes.
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13
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Fox DE, King-Shier KM, James MT, Venturato L, Clarke A, Ravani P, Oliver MJ, Quinn RR. The availability of support and peritoneal dialysis survival: A cohort study. ARCH ESP UROL 2022; 42:353-360. [PMID: 35353014 DOI: 10.1177/08968608221086752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Providing support is important to maintain a patient on peritoneal dialysis (PD), though its impact on outcomes has not been investigated thoroughly. We examined the association between having support and risk of a transfer to hemodialysis. METHODS In this retrospective observational cohort study, we used data captured in the Dialysis Measurement Analysis and Reporting system about patients who started PD in Alberta, Canada, between 1 January 2013 and 30 September 2018. Support was defined as the availability of a support person in the home who was able, willing and available to provide support for PD in the patient's residence. The outcome of interest was a transfer to hemodialysis for at least 90 days. We estimated the cumulative incidence of a transfer over time accounting for competing risks and hazard ratios to summarise the association between support and a transfer. We split follow-up time as hazard ratios varied over time. RESULTS Six hundred and eighty-three incident PD patients, median age 58 years (IQR: 47-68) and 35% female, were followed for a median of 15 months. The cumulative incidence of a transfer to hemodialysis at 24 months was 26%. Having support was associated with a reduced risk of a transfer between 3 and 12 months after the start of dialysis (HR3-12mo: 0.44; 95% CI: 0.25-0.78), but not earlier (hazard ratio (HR)<3mo: 0.96; 95% confidence interval (CI): 0.55-1.69) or later (HR>12mo: 1.19; 95% CI: 0.65-2.17). CONCLUSIONS A transfer to hemodialysis is common. Having a support person at home is associated with a short-term protective effect after the initiation of PD.
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Affiliation(s)
- Danielle E Fox
- Department of Community Health Sciences, The University of Calgary, Alberta, Canada
| | - Kathryn M King-Shier
- Faculty of Nursing and Department of Community Health Sciences, The University of Calgary, Alberta, Canada
| | - Matthew T James
- Departments of Medicine and Community Health Sciences, The University of Calgary, Alberta, Canada
| | | | - Alix Clarke
- Department of Medicine, The University of Calgary, Alberta, Canada
| | - Pietro Ravani
- Departments of Medicine and Community Health Sciences, The University of Calgary, Alberta, Canada
| | - Matthew J Oliver
- Division of Nephrology, Department of Medicine, The University of Toronto, Ontario, Canada
| | - Robert R Quinn
- Departments of Medicine and Community Health Sciences, The University of Calgary, Alberta, Canada
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14
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Manns BJ, Garg AX, Sood MM, Ferguson T, Kim SJ, Naimark D, Nesrallah GE, Soroka SD, Beaulieu M, Dixon SN, Alam A, Allu S, Tangri N. Multifaceted Intervention to Increase the Use of Home Dialysis: A Cluster Randomized Controlled Trial. Clin J Am Soc Nephrol 2022; 17:535-545. [PMID: 35314481 PMCID: PMC8993468 DOI: 10.2215/cjn.13191021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 02/03/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES Home dialysis therapies (peritoneal and home hemodialysis) are less expensive and provide similar outcomes to in-center hemodialysis, but they are underutilized in most health systems. Given this, we designed a multifaceted intervention to increase the use of home dialysis. In this study, our objective was to evaluate the effect of this intervention on home dialysis use in CKD clinics across Canada. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a cluster randomized controlled trial in 55 CKD clinic clusters in nine provinces in Canada between October 2014 and November 2015. Participants included all adult patients who initiated dialysis in the year following the intervention. We evaluated the implementation of a four-component intervention, which included phone surveys from a knowledge translation broker, a 1-year center-specific audit/feedback on home dialysis use, delivery of an educational package (including tools aimed at both providers and patients), and an academic detailing visit. The primary outcome was the proportion of patients using home dialysis at 180 days after dialysis initiation. RESULTS A total of 55 clinics were randomized (27 in the intervention and 28 in the control), with 5312 patients initiating dialysis in the 1-year follow-up period. In the primary analysis, there was no difference in the use of home dialysis at 180 days in the intervention and control clusters (absolute risk difference, 4%; 95% confidence interval, -2% to 10%). Using a difference-in-difference comparison, the use of home dialysis at 180 days was similar before and after implementation of the intervention (difference of 0% in intervention clinics; 95% confidence interval, -2% to 3%; difference of 0.8% in control clinics; 95% confidence interval, -1% to 3%; P=0.84). CONCLUSIONS A multifaceted intervention did not increase the use of home dialysis in adults initiating dialysis. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER A Cluster Randomized Trial to Assess the Impact of Patient and Provider Education on Use of Home Dialysis, NCT02202018.
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Affiliation(s)
- Braden J Manns
- Department of Medicine and Community Health Sciences, Libin Cardiovascular Institute and O'Brien Public Health Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Amit X Garg
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Manish M Sood
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Thomas Ferguson
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - S Joseph Kim
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Department of Medicine, Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
| | - David Naimark
- Division of Nephrology, Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, Canada
| | - Gihad E Nesrallah
- Li Ka Shing Knowledge Institute, Keenan Research Centre, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Steven D Soroka
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Monica Beaulieu
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Stephanie N Dixon
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Ahsan Alam
- Division of Nephrology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Selina Allu
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Navdeep Tangri
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
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15
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Impact of the Type of Dialysis on Time to Transplantation: Is It Just a Matter of Immunity? J Clin Med 2022; 11:jcm11041054. [PMID: 35207326 PMCID: PMC8874533 DOI: 10.3390/jcm11041054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/11/2022] [Accepted: 02/16/2022] [Indexed: 01/27/2023] Open
Abstract
Background: Renal transplantation represents the therapeutic gold standard in patients with end stage renal disease (ESRD). Still the role of pre-transplant dialysis in affecting time to transplantation has yet to be determined. We wanted to verify whether the type of renal replacement therapy (hemodialysis vs. peritoneal dialysis) affects time to transplantation and to identify clinical features related to the longer time to transplantation. Methods: We performed a retrospective single-center observational study on patients who had received a transplant in the Bologna Transplant Unit from 1991 to 2019, described through the analysis of digital transplant list documents for sex, age, body mass index (BMI), blood group, comorbidities, underlying disease, serology, type of dialysis, time to transplantation, Panel Reactive Antibodies (PRA) max, number of preformed anti Human Leukocyte Antigens (HLA) antibodies. A p-value < 0.05 was considered statistically significant. Results: In the 1619 patients analyzed, we observed a significant difference in time to transplant, PRA max and Preformed Antibodies Number between patients who received Hemodialysis (HD) and Peritoneal dialysis (PD). Then we performed a multiple regression analysis with all the considered factors in order to identify features that support these differences. The clinical variables that independently and directly correlate with longer time to transplantation are PRA max (p < 0.0001), Antibodies number (p < 0.0001) and HD (p < 0.0001); though AB blood group (p < 0.0001), age (p < 0.003) and PD (p < 0.0001) inversely correlate with time to transplantation. Conclusions: In our work, PD population received renal transplants in a shorter period of time compared to HD and turned out to be less immunized. Considering immunization, the type of dialysis impacts both on PRA max and on anti HLA antibodies.
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16
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Yu X, Nakayama M, Wu MS, Kim YL, Mushahar L, Szeto CC, Schatell D, Finkelstein FO, Quinn RR, Duddington M. Shared Decision-Making for a Dialysis Modality. Kidney Int Rep 2022; 7:15-27. [PMID: 35005310 PMCID: PMC8720663 DOI: 10.1016/j.ekir.2021.10.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 10/14/2021] [Accepted: 10/18/2021] [Indexed: 02/06/2023] Open
Abstract
The prevalence of kidney failure continues to rise globally. Dialysis is a treatment option for individuals with kidney failure; after the decision to initiate dialysis has been made, it is critical to involve individuals in the decision on which dialysis modality to choose. This review, based on evidence arising from the literature, examines the role of shared decision-making (SDM) in helping those with kidney failure to select a dialysis modality. SDM was found to lead to more people with kidney failure feeling satisfied with their choice of dialysis modality. Individuals with kidney failure must be cognizant that SDM is an active and iterative process, and their participation is essential for success in empowering them to make decisions on dialysis modality. The educational components of SDM must be easy to understand, high quality, unbiased, up to date, and targeted to the linguistic, educational, and cultural needs of the individual. All individuals with kidney failure should be encouraged to participate in SDM and should be involved in the design and implementation of SDM approaches.
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Affiliation(s)
- Xueqing Yu
- Division of Nephrology, Guangdong Provincial People’s Hospital, Guangzhou, People’s Republic of China
- Correspondence: Xueqing Yu, Division of Nephrology, Guangdong Provincial People’s Hospital, 106th, Zhongshan Road II, Guangzhou 510080, People’s Republic of China.
| | | | - Mai-Szu Wu
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan
| | - Yong-Lim Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Lily Mushahar
- Department of Nephrology, Hospital Tuanku Ja'afar, Seremban, Malaysia
| | - Cheuk Chun Szeto
- Department of Medicine & Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Dori Schatell
- Medical Education Institute, Inc., Madison, Wisconsin, USA
| | | | - Robert R. Quinn
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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17
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Hasan MZ, Biswas NK, Aziz AM, Chowdhury J, Haider SS, Sarker M. Clinical profile and short-term outcomes of RT-PCR- positive patients with COVID-19: a cross-sectional study in a tertiary care hospital in Dhaka, Bangladesh. BMJ Open 2021; 11:e055126. [PMID: 34911722 PMCID: PMC8678562 DOI: 10.1136/bmjopen-2021-055126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE The COVID-19 pandemic is still raging worldwide. While there is significant published evidence on the attributes of patients with COVID-19 from lower-income and middle-income countries, there is a dearth of original research published from Bangladesh, a low-income country in Southeast Asia. Based on a case series from a tertiary healthcare centre, this observational study has explored the epidemiology, clinical profile of patients with COVID-19 and short-term outcomes in Dhaka, Bangladesh. DESIGN AND SETTING A total of 422 COVID-19-confirmed patients (via reverse transcription-PCR test) were enrolled in this study (male=271, female=150, 1 unreported). We have compiled medical records of the patients and descriptively reported their demographic, socioeconomic and clinical features, treatment history, health outcomes, and postdischarge complications. RESULT Patients were predominantly male (64%), between 35 and 49 years (28%), with at least one comorbidity (52%), and had COVID-19 symptoms for 1 week before hospitalisation (66%). A significantly higher proportion (p<0.05) of male patients had diabetes, hypertension and ischaemic heart disease, while female patients had asthma (p<0.05). The most common symptoms were fever (80%), cough (60%), dyspnoea (41%) and sore throat (21%). The majority of the patients received antibiotics (77%) and anticoagulant therapy (56%) and stayed in the hospital for an average of 12 days. Over 90% of patients were successfully weaned, while 3% died from COVID-19, and 41% reported complications after discharge. CONCLUSION The diversity of clinical and epidemiological characteristics and health outcomes of patients with COVID-19 across age groups and gender is noteworthy. Our result will inform the clinicians and epidemiologists of Bangladesh of their COVID-19 mitigation effort.
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Affiliation(s)
- Md Zabir Hasan
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | | - Juli Chowdhury
- National Institute of Cardiovascular Diseases, Dhaka, Bangladesh
| | - Shams Shabab Haider
- BRAC James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
| | - Malabika Sarker
- BRAC James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
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18
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Heaf J, Heiro M, Petersons A, Vernere B, Povlsen JV, Sørensen AB, Clyne N, Bumblyte I, Zilinskiene A, Randers E, Løkkegaard N, Ots-Rosenberg M, Kjellevold S, Kampmann JD, Rogland B, Lagreid I, Heimburger O, Lindholm B. Choice of dialysis modality among patients initiating dialysis: results of the Peridialysis study. Clin Kidney J 2021; 14:2064-2074. [PMID: 34476093 PMCID: PMC8406075 DOI: 10.1093/ckj/sfaa260] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 11/30/2020] [Indexed: 12/16/2022] Open
Abstract
Background In patients with end-stage kidney disease (ESKD), home dialysis offers socio-economic and health benefits compared with in-centre dialysis but is generally underutilized. We hypothesized that the pre-dialysis course and institutional factors affect the choice of dialysis modality after dialysis initiation (DI). Methods The Peridialysis study is a multinational, multicentre prospective observational study assessing the causes and timing of DI and consequences of suboptimal DI. Clinical and biochemical data, details of the pre-dialytic course, reasons for DI and causes of the choice of dialysis modality were registered. Results Among 1587 included patients, 516 (32.5%) were judged unsuitable for home dialysis due to contraindications [384 ( 24.2%)] or no assessment [106 (6.7%); mainly due to late referral and/or suboptimal DI] or death [26 (1.6%)]. Older age, comorbidity, late referral, suboptimal DI, acute illness and rapid loss of renal function associated with unsuitability. Of the remaining 1071 patients, 700 (65.4%) chose peritoneal dialysis (61.7%) or home haemodialysis (HD; 3.6%), while 371 (34.6%) chose in-centre HD. Somatic differences between patients choosing home dialysis and in-centre dialysis were minor; factors linked to the choice of in-centre dialysis were late referral, suboptimal DI, acute illness and absence of a ‘home dialysis first’ institutional policy. Conclusions Given a personal choice with shared decision making, 65.4% of ESKD patients choose home dialysis. Our data indicate that the incidence of home dialysis potentially could be further increased to reduce the incidence of late referral and unplanned DI and, in acutely ill patients, by implementing an educational programme after improvement of their clinical condition.
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Affiliation(s)
- James Heaf
- Department of Medicine, Zealand University Hospital, Roskilde, Denmark.,Department of Nephrology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Maija Heiro
- Department of Medicine, Turku University Hospital, Turku, Finland
| | - Aivars Petersons
- Latvia Nephrology Department, P. Stradins University Hospital, Riga, Latvia
| | - Baiba Vernere
- Latvia Nephrology Department, P. Stradins University Hospital, Riga, Latvia
| | - Johan V Povlsen
- Department of Nephrology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Naomi Clyne
- Department of Nephrology, Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Inge Bumblyte
- Nephrological Clinic, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Alanta Zilinskiene
- Nephrological Clinic, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Else Randers
- Department of Medicine, Viborg Regional Hospital, Viborg, Denmark
| | | | - Mai Ots-Rosenberg
- Department of Nephrology, University Hospital of Tartu, Tartu, Estonia
| | | | | | - Björn Rogland
- Department of Medicine, Kristianstad Hospital, Kristianstad, Sweden
| | - Inger Lagreid
- Department of Medicine, St Olav University Hospital, Trondheim, Norway
| | - Olof Heimburger
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Bengt Lindholm
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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19
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Jiang X, Wang Y, Xiao A, Feng S. Patients undergoing assisted peritoneal dialysis to show a better technique survival: A competing risk analysis. Int J Clin Pract 2021; 75:e14192. [PMID: 33792114 DOI: 10.1111/ijcp.14192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 03/27/2021] [Indexed: 11/29/2022] Open
Abstract
AIMS To compare patient mortality and technique survival between patients undergoing assisted peritoneal dialysis (aPD) and self-care peritoneal dialysis (sPD). METHODS Patients who underwent peritoneal dialysis (PD) at the dialysis center of Second Affiliated Hospital of Soochow University from January 1, 2012 to December 31, 2016, were included and followed to December 31, 2019. Subjects were divided into aPD and sPD groups according to whether the patient could independently complete the PD procedure. Differences in mortality and technique failure rates were compared using competing risk analysis. RESULTS A total of 384 patients were included in this study, with 274 patients in the sPD group and 110 patients in the aPD group. The multivariate competing risk regression analysis revealed that age (HR 1.03,95%CI 1.01-1.05, P < .001), aPD (HR 1.84,95%CI 1.10-3.08, P = .02), diabetes (HR 1.51, 95%CI 1.00-2.30, P = .05), residual renal function (HR 0.89, 95%CI 0.82-0.97, P = .005) and serum albumin level (HR 0.92, 95% CI 0.89-0.96, P < .001) were the independent risk factors for mortality. Besides, technique failure in aPD patients was lower than in the sPD group (HR 0.85, 95% CI 0.68-0.97, P = .03). CONCLUSION These results found that aPD patients had higher mortality rates but lower technique failure rates than sPD patients. Higher mortality in aPD is probably related to the negative selection of the more comorbid patients. .
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Affiliation(s)
- Xiaomei Jiang
- Department of Nursing, Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Yun Wang
- Department of Nursing, Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Aihua Xiao
- Department of Nursing, Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Sheng Feng
- Department of Nephrology, Second Affiliated Hospital of Soochow University, Suzhou, China
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20
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Mok NMY, Fan N, Finney H, Fan SLS. Relationship between sodium removal, hydration and outcomes in peritoneal dialysis patients. Nephrology (Carlton) 2021; 26:676-683. [PMID: 33893694 DOI: 10.1111/nep.13885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 04/14/2021] [Accepted: 04/15/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Fluid overload (FO) in peritoneal dialysis (PD) patients is associated with mortality. We explore if low daily sodium removal is an independent risk factor for mortality. We examined severely FO PD patients established for >1 year in expectation that PD prescription would have been optimized for solute clearance and ultrafiltration. We also wish to determine the relationship between kt/v and sodium removal. METHODS Retrospective analysis of 231 PD patients with FO ≥2.0 L and compared with 218 PD patients who were euvolaemic throughout their PD treatment. Patients were followed up until death censored for transplantation. RESULTS Mean daily sodium removal in overhydrated patients was only 75 mmoles (=1.7 g). CAPD usage was more common in patients with the highest sodium removal. Achievement of UK guidelines for solute clearance and daily fluid removal were not independent predictors of mortality. Markers of sarcopenia (low serum albumin and high CRP) were associated with increased mortality, but these parameters were not independent predictors in a model that included functional assessment (Karnofsky score). Daily sodium removal was not predictive of mortality but the imprecision of clinically used sodium assay should be noted. The correlation between Na and kt/v is statistically significant but R2 was weak at .07. CONCLUSION While diabetic males were more likely to become overhydrated, these factors did not increase mortality further. Traditional targets of 'dialysis adequacy' did not predict survival. Kt/v is not a good indicator of sodium removal which can be surprisingly low. Measuring sodium clearance may help clinicians optimize PD modality (CAPD vs. APD).
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Affiliation(s)
- Natalie M-Y Mok
- Departments of Renal Medicine and Transplantation, Barts Health NHS Trust, London, United Kingdom
| | - Nicholas Fan
- Departments of Renal Medicine and Transplantation, Barts Health NHS Trust, London, United Kingdom
| | - Hazel Finney
- Department of Clinical Biochemistry, Barts Health NHS Trust, London, United Kingdom
| | - Stanley L-S Fan
- Departments of Renal Medicine and Transplantation, Barts Health NHS Trust, London, United Kingdom
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21
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Quinn RR, Mohamed F, Pauly R, Schwartz T, Scott-Douglas N, Morrin L, Kozinski A, Manns BJ, Klarenbach S, Clarke A, Fox DE, Oliver MJ. Starting Dialysis on Time, At Home on the Right Therapy (START): Description of an Intervention to Increase the Safe and Effective Use of Peritoneal Dialysis. Can J Kidney Health Dis 2021; 8:20543581211003764. [PMID: 33868692 PMCID: PMC8020238 DOI: 10.1177/20543581211003764] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 02/16/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Most of the patients with end-stage kidney failure are treated with dialysis. Jurisdictions around the world are actively promoting peritoneal dialysis (PD) because it is equivalent to hemodialysis in terms of clinical outcomes, but is less costly. Unfortunately, PD penetration remains low. Objectives: The Starting dialysis on Time, At Home, on the Right Therapy (START) Project had 2 overarching goals: (1) to provide information that would help programs increase the safe and effective use of PD, and (2) to reduce inappropriate, early initiation of dialysis in patients with kidney failure. In this article, we focus on the first objective and describe the rationale for START and the methods employed. Design: The START Project was a comprehensive, province-wide quality improvement intervention. Setting: The START project was implemented in both Alberta Kidney Care (AKC)-South and AKC-North, including all 7 renal programs in the province. Patients: The project included all patients who commenced maintenance dialysis between October 1, 2015, and March 31, 2018, in Alberta, Canada who met our inclusion criteria. Measurements: We reported baseline characteristics of incident dialysis patients overall, and by site. Our key performance indicator was the proportion of patients who received PD for any period of time within 180 days of the first dialysis treatment. Reports also included detailed metrics pertaining to the 6 steps in the process of modality selection and we had the capacity to provide more granular data on an as-needed basis. To understand loss of PD patients, we reported the numbers of incident patients who recovered kidney function, experienced technique failure, received a transplant, were lost to follow-up, transferred to another program, or died. Methods: START provided dialysis programs with a conceptual framework for understanding the drivers of PD utilization. High-quality, detailed data were collected using a tool that was custom-built for this purpose, and were mapped to steps in the process of care that drove the outcomes of interest. This allowed sites to identify gaps in care, develop action plans, and implement local interventions to address them. The process was supported by an Innovation Learning Collaborative consisting of 3 learning sessions that brought frontline staff together from across the province to share strategies and learnings. Ongoing data collection allowed teams to determine whether their interventions were effective at each subsequent learning session, and to revisit their interventions if required (the “Plan-Do-Study-Act Cycle”). Results: Future work will report on the impact of the START project on incident PD utilization at a provincial and regional level. Limitations: The time required to design and implement interventions in practice, as well as the need for multiple PDSA (Plan-Do-Study-Act) cycles to see results, meant that the true potential may not be realized during a relatively short intervention period. Change required buy-in and support from local and provincial leadership and frontline staff. In the absence of accountability for local performance, we relied on the goodwill of participating programs to use the information and resources provided to effect change. Finally, the burden of documentation and data collection for frontline staff was high at baseline. We anticipated that adding supplemental data collection would be difficult. Conclusions: The START project was a comprehensive, province-wide initiative to maximize the safe and effective use of PD in Alberta, Canada. It standardized the management of incident dialysis patients, leveraged high-quality data to facilitate the reporting of metrics mapped to steps in the process of care that drove incident PD utilization, and helped programs to identify gaps in care and target them for improvement. Future work will report on the impact of the program on incident utilization at the provincial and regional level.
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Affiliation(s)
- Robert R Quinn
- Cumming School of Medicine, University of Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, AB, Canada
| | | | - Robert Pauly
- Department of Medicine, University of Alberta, Edmonton, Canada
| | | | | | | | | | - Braden J Manns
- Cumming School of Medicine, University of Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, AB, Canada
| | - Scott Klarenbach
- Department of Medicine, University of Alberta, Edmonton, Canada.,Institute of Health Economics, Edmonton, Canada
| | - Alix Clarke
- Cumming School of Medicine, University of Calgary, AB, Canada
| | - Danielle E Fox
- Cumming School of Medicine, University of Calgary, AB, Canada
| | - Matthew J Oliver
- Department of Medicine, Division of Nephrology, University of Toronto, ON, Canada
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22
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Elsayed ME, Morris AD, Li X, Browne LD, Stack AG. Propensity score matched mortality comparisons of peritoneal and in-centre haemodialysis: systematic review and meta-analysis. Nephrol Dial Transplant 2021; 35:2172-2182. [PMID: 31981353 PMCID: PMC7716812 DOI: 10.1093/ndt/gfz278] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 11/26/2019] [Indexed: 01/25/2023] Open
Abstract
Background Accurate comparisons of haemodialysis (HD) and peritoneal dialysis (PD) survival based on observational studies are difficult due to substantial residual confounding that arises from imbalances between treatments. Propensity score matching (PSM) comparisons confer additional advantages over conventional methods of adjustment by further reducing selection bias between treatments. We conducted a systematic review of studies that compared mortality between in-centre HD with PD using a PSM-based approach. Methods A sensitive search strategy identified all citations in the PubMed, Cochrane and EMBASE databases from inception through November 2018. Pooled PD versus HD mortality hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated through random-effects meta-analysis. A subsequent meta-regression explored factors to account for between-study variation. Results The systematic review yielded 214 citations with 17 cohort studies and 113 578 PSM incident dialysis patients. Cohort periods spanned the period 1993–2014. The pooled HR for PD versus HD was 1.06 (95% CI 0.99–1.14). There was considerable variation by country, however, mortality risks for PD versus HD remained virtually unchanged when stratified by geographical region with HRs of 1.04 (95% CI 0.94–1.15), 1.14 (95% CI 0.99–1.32) and 0.98 (0.87–1.10) for European, Asian and American cohorts, respectively. Subgroup meta-analyses revealed similar risks for patients with diabetes [HR 1.09 (95% CI 0.98–1.21)] and without diabetes [HR 0.99 (95% CI 0.90–1.09)]. Heterogeneity was substantial (I2 = 87%) and was largely accounted for by differences in cohort period, study type and country of origin. Together these factors explained a substantial degree of between-studies variance (R2 = 90.6%). Conclusions This meta-analysis suggests that PD and in-centre HD carry equivalent survival benefits. Reported differences in survival between treatments largely reflect a combination of factors that are unrelated to clinical efficacy.
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Affiliation(s)
- Mohamed E Elsayed
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland.,Department of Nephrology, Royal Preston Hospital, Preston, UK
| | - Adam D Morris
- Department of Nephrology, Royal Preston Hospital, Preston, UK
| | - Xia Li
- Departments of Mathematics and Statistics, La Trobe University, Melbourne, Victoria, Australia
| | - Leonard D Browne
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Austin G Stack
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland.,Department of Nephrology, University Hospital Limerick, Limerick, Ireland.,Health Research Institute, University of Limerick, Limerick, Ireland
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23
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Molnar AO, Bota SE, Garg AX, Ouédraogo A, Dixon SN, Naylor K, Oliver M, Sood MM. Dialysis Modality and Mortality in Heart Failure: A Retrospective Study of Incident Dialysis Patients. Cardiorenal Med 2020; 10:452-461. [PMID: 33238287 DOI: 10.1159/000511168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 08/25/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Prior studies reported lower mortality with hemodialysis (HD) compared to peritoneal dialysis (PD) in patients with heart failure (HF). We examined mortality rate by initial dialysis modality in incident dialysis patients with a history of HF using contemporary data and methods that ensure comparable HD and PD groups. METHODS Retrospective cohort study using administrative databases in Ontario, Canada. Adults (age 50-80) with a history of HF who initiated maintenance dialysis between April 1, 2007 and March 31, 2016 were included. We excluded patients typically ineligible for PD as an initial modality (dialysis start in hospital, dementia, long-term care facility residency). We determined the cause-specific hazard ratio (transplant as a competing event) between initial dialysis modality (HD vs. PD) and all-cause mortality using an intention-to-treat approach. RESULTS We included 2,199 patients with HF who initiated maintenance dialysis (77% HD and 23% PD). There were 1,152 (67.8%) and 340 (68.1%) mortality events over a median follow-up of 2.4 and 2.5 years in the HD and PD groups, respectively. Patients initiating HD versus PD was not associated with the mortality rate (adjusted hazard ratio 1.0, 95% CI 0.9-1.1). Similar results were seen in analyses censoring at modality switches and treating modality as time-varying. CONCLUSIONS We found no difference in mortality by initial dialysis modality. Our data support the current practice of selecting dialysis modality based on patient preference for patients with pre-existing HF.
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Affiliation(s)
- Amber O Molnar
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada, .,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada, .,ICES, Toronto, Ontario, Canada,
| | | | - Amit X Garg
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada.,Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | | | | | | | - Matthew Oliver
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Manish M Sood
- ICES, Toronto, Ontario, Canada.,Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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24
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Weinhandl ED, Gilbertson DT. Relative Survival With Peritoneal Dialysis: The Hunt for a Comparator Continues. Kidney Med 2020; 2:678-680. [PMID: 33320112 PMCID: PMC7729254 DOI: 10.1016/j.xkme.2020.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
- Eric D. Weinhandl
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, MN
| | - David T. Gilbertson
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN
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25
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Jeong JC, Kim S, Kim KP, Yi Y, Ahn SY, Jin DC, Chin HJ, Chae DW, Na KY. Changes in mortality hazard of the Korean long-term dialysis population: The dependencies of time and modality switch. Perit Dial Int 2020; 41:69-78. [PMID: 32319853 DOI: 10.1177/0896860820915024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Jong Cheol Jeong
- Department of Internal Medicine, 65462Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Sejoong Kim
- Department of Internal Medicine, 65462Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Ki Pyo Kim
- Department of Internal Medicine, 65462Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Yongjin Yi
- Department of Internal Medicine, 65462Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Shin Young Ahn
- Division of Nephrology, Department of Internal Medicine, Korea University Medical Center, 58934Korea University Guro Hospital, Seoul, Republic of Korea
| | - Dong-Chan Jin
- Department of Internal Medicine, College of Medicine, The 34923Catholic University of Korea, Seoul, Republic of Korea
| | - Ho Jun Chin
- Department of Internal Medicine, 65462Seoul National University Bundang Hospital, Seongnam, Republic of Korea.,Department of Internal Medicine, College of Medicine, 65462Seoul National University, Republic of Korea
| | - Dong-Wan Chae
- Department of Internal Medicine, 65462Seoul National University Bundang Hospital, Seongnam, Republic of Korea.,Department of Internal Medicine, College of Medicine, 65462Seoul National University, Republic of Korea
| | - Ki Young Na
- Department of Internal Medicine, 65462Seoul National University Bundang Hospital, Seongnam, Republic of Korea.,Department of Internal Medicine, College of Medicine, 65462Seoul National University, Republic of Korea
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26
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Marshall MR. The benefit of early survival on PD versus HD—Why this is (still) very important. Perit Dial Int 2020; 40:405-418. [DOI: 10.1177/0896860819895177] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
- Mark R Marshall
- Department of Renal Medicine, Counties Manukau District Health Board, Auckland, New Zealand
- School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Medical Affairs, Baxter Healthcare (Asia) Pte Ltd, Singapore
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27
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Changsirikulchai S, Sriprach S, Thokanit NS, Janma J, Chuengsaman P, Sirivongs D. Survival Analysis and Associated Factors in THAI Patients on Peritoneal Dialysis under the PD-First Policy. Perit Dial Int 2020; 38:172-178. [DOI: 10.3747/pdi.2017.00127] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 11/30/2017] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Siribha Changsirikulchai
- Renal Division, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Suwannee Sriprach
- Department of Medicine, Faculty of Medicine, Srinakharinwirot University, Nakhonnayok, Thailand; The National Health Security Office Region 4, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Nintita Sripaiboonkij Thokanit
- Saraburi, Thailand; Ramathibodi Comprehensive Cancer Center, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Jirayut Janma
- Renal Division, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Piyatida Chuengsaman
- Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Thailand; Banphaeo Dialysis Group (Bangkok), Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Dhavee Sirivongs
- Banphaeo Hospital (Public organization), Bangkok, Thailand; and Renal Division, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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Thiery A, Séverac F, Hannedouche T, Couchoud C, Do VH, Tiple A, Béchade C, Sauleau EA, Krummel T. Survival advantage of planned haemodialysis over peritoneal dialysis: a cohort study. Nephrol Dial Transplant 2019; 33:1411-1419. [PMID: 29447408 DOI: 10.1093/ndt/gfy007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 12/22/2017] [Indexed: 11/14/2022] Open
Abstract
Background Previous studies comparing the outcomes in haemodialysis (HD) with those in peritoneal dialysis (PD) have yielded conflicting results. Methods The aim of the study was to compare the survival of planned HD versus PD patients in a cohort of adult incident patients who started renal replacement therapy (RRT) between 2006 and 2008 in the nationwide REIN registry (Réseau Epidémiologie et Information en Néphrologie). Patients who started RRT in emergency or stopped RRT within 2 months were excluded. Adjusted Cox models, propensity score matching and marginal structural models (MSMs) were used to compensate for the lack of randomization and provide causal inference from longitudinal data with time-dependent treatments and confounders including transplant censorship, modality change over time and time-varying covariates. Results Among a total of 13 767 dialysis patients, 13% were on PD at initiation of RRT and 87% were on HD. The median survival times were 53.5 months or 4.45 years and 38.6 months or 3.21 years for patients starting on HD and PD, respectively. Regardless of the model used, there was a consistent advantage in terms of survival for HD patients: hazard ratio (HR) 0.76 [95% confidence interval (95% CI) 0.69-0.84] with the Cox model using propensity score; HR 0.67 (95% CI 0.62-0.73) in the Cox model with censorship for each treatment change; and HR 0.82 (95% CI 0.69-0.97) with MSMs. However, MSMs tended to reduce the survival gap between PD and HD patients. Conclusion This large cohort study using various statistical methods to minimize the bias appears to demonstrate a better survival in planned HD than in PD.
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Affiliation(s)
- Alicia Thiery
- Department of Public Health, Centre Paul Strauss, Strasbourg, France
| | - François Séverac
- Department of Public Health, Strasbourg University Hospital, Strasbourg, France.,Biostatistical Laboratory, Laboratory ICube, University of Strasbourg, Strasbourg, France
| | - Thierry Hannedouche
- School of Medicine, University of Strasbourg, Strasbourg, France.,Department of Nephrology and Dialysis, Strasbourg University Hospital, Strasbourg, France
| | | | - Van Huyen Do
- Biostatistical Laboratory, Laboratory ICube, University of Strasbourg, Strasbourg, France
| | - Aurélien Tiple
- Department of Nephrology, Dialysis and Transplantation, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Clémence Béchade
- Department of Nephrology, Dialysis and Transplantation, Caen University Hospital, Caen, France
| | - Erik-Andre Sauleau
- Department of Public Health, Strasbourg University Hospital, Strasbourg, France.,Biostatistical Laboratory, Laboratory ICube, University of Strasbourg, Strasbourg, France.,School of Medicine, University of Strasbourg, Strasbourg, France
| | - Thierry Krummel
- Department of Nephrology and Dialysis, Strasbourg University Hospital, Strasbourg, France
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29
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Jaar BG, Gimenez LF. Dialysis Modality Survival Comparison: Time to End the Debate, It's a Tie. Am J Kidney Dis 2019; 71:309-311. [PMID: 29477176 DOI: 10.1053/j.ajkd.2017.10.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Accepted: 10/19/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Bernard G Jaar
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD; Nephrology Center of Maryland, Baltimore, MD.
| | - Luis F Gimenez
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Nephrology Center of Maryland, Baltimore, MD
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30
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Wilk AS, Hirth RA, Messana JM. Paying for Frequent Dialysis. Am J Kidney Dis 2019; 74:248-255. [PMID: 30922595 PMCID: PMC7758184 DOI: 10.1053/j.ajkd.2019.01.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 01/29/2019] [Indexed: 11/11/2022]
Abstract
In late 2017, the 7 regional contractors responsible for paying dialysis claims in Medicare proposed new payment rules that would restrict payment for hemodialysis treatments in excess of 3 weekly to exceptional acute-care circumstances. Frequent hemodialysis is performed more frequently than the traditional thrice-weekly pattern, and many stakeholders-patients, providers, dialysis machine manufacturers, and others-have expressed concern that these payment rules will inhibit the growth of this treatment modality's use among US dialysis patients. In this Perspective, we explain the role of these contractors in the context of Medicare's in-center hemodialysis-centric dialysis payment system and assess how well this system accommodates the higher treatment frequencies of both peritoneal dialysis and frequent hemodialysis. Then, given the available evidence concerning the relative effectiveness of these modalities versus thrice-weekly in-center hemodialysis and trends in their use, we discuss options for modifying Medicare's payment system to support frequent dialysis.
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Affiliation(s)
- Adam S Wilk
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA.
| | - Richard A Hirth
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI
| | - Joseph M Messana
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI; Division of Nephrology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI
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31
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Browne JA, Casp AJ, Cancienne JM, Werner BC. Peritoneal Dialysis Does Not Carry the Same Risk as Hemodialysis in Patients Undergoing Hip or Knee Arthroplasty. J Bone Joint Surg Am 2019; 101:1271-1277. [PMID: 31318806 DOI: 10.2106/jbjs.18.00936] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Dialysis has been associated with increased complication rates following total hip arthroplasty (THA) and total knee arthroplasty (TKA). The current literature on this issue is limited and does not distinguish between hemodialysis and peritoneal dialysis. The purpose of this study was to determine (1) the differences in the infection and other complication rates after THA or TKA between patients on peritoneal dialysis and those on hemodialysis and (2) the differences in complication rates after THA or TKA between patients on peritoneal dialysis and matched controls without dialysis dependence. METHODS Patients who had undergone primary THA or TKA from 2005 to 2014 were identified in the 100% Medicare files; 531 patients who underwent TKA and 572 patients who underwent THA were on peritoneal dialysis. These patients were matched 1:1 to patients on hemodialysis and 1:3 with patients who were not receiving either form of dialysis. Multivariate regression analysis was performed to examine several adverse events, including the prevalence of infection at 1 year and hospital readmission at 30 days. RESULTS The infection rates at 1 year after THA were significantly lower in the peritoneal dialysis group than in the hemodialysis group: 1.57% (95% confidence interval [CI] = 0.7% to 3.0%) and 4.20% (95% CI = 2.7% to 6.2%), respectively, with an odds ratio (OR) of 0.30 (95% CI = 0.12 to 0.71). This was also the case for the infection rates 1 year after TKA (3.39% [95% CI = 2.0% to 5.3%] and 6.03% [95% CI = 4.2% to 8.4%], respectively; OR = 0.67 [95% CI = 0.49 to 0.93]). Peritoneal dialysis appears to result in a similar infection rate when compared with matched controls. The rates of other assessed complications, such as hospital readmission, emergency room visits, and mortality, were very similar between the peritoneal dialysis and hemodialysis groups but were often significantly higher than the rates in non-dialysis-dependent controls. CONCLUSIONS The increased risk of complications in dialysis-dependent patients following THA or TKA depends on the mode of the dialysis. Whereas patients on hemodialysis have a significantly higher risk of infection, patients on peritoneal dialysis do not appear to have this same risk when compared with non-dialysis-dependent patients. These results suggest that the mode of dialysis should be considered when assessing the risk associated with THA or TKA. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- James A Browne
- Department of Orthopedic Surgery, University of Virginia, Charlottesville, Virginia
| | - Aaron J Casp
- Department of Orthopedic Surgery, University of Virginia, Charlottesville, Virginia
| | - Jourdan M Cancienne
- Department of Orthopedic Surgery, University of Virginia, Charlottesville, Virginia
| | - Brian C Werner
- Department of Orthopedic Surgery, University of Virginia, Charlottesville, Virginia
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32
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Ludwig S, Theis C, Wolff C, Nicolle E, Witthohn A, Götte A. Complications and associated healthcare costs of transvenous cardiac pacemakers in Germany. J Comp Eff Res 2019; 8:589-597. [PMID: 31099255 DOI: 10.2217/cer-2018-0114] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: This study evaluated the occurrence and associated costs of pacemaker complications in Germany from 2010 to 2013. Patients & methods: Patients with a de novo or replacement implantation of a single or dual chamber pacemaker between 2010 and 2013 were followed for 12 months post-implant using German health insurance claims data. A case-control analysis was performed using propensity score matching to estimate the costs of complications. Results: Out of 12,922 implanted patients, 12.0% had a complication in the year following the implant. Complications related to lead and pocket were found in 10.2% of all implanted patients; infections occurred in 1.7% patients. Healthcare costs up to 36 months post complication were on average €4627 higher than for pacemaker patients without a complication. Conclusion: Pacemaker complications are common and represent a burden for patients and healthcare systems generating substantial costs. Most of the pacemaker complications involved the pacing lead or pacemaker pocket.
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Affiliation(s)
- Saskia Ludwig
- HGC GesundheitsConsult GmbH, Mörsenbroicher Weg 200, 40470 Duesseldorf, Germany
| | - Cathrin Theis
- Robert-Bosch-Krankenhaus, Zentrum für Innere Medizin III Kardiologie, Auerbachstraße 110, 70376 Stuttgart, Germany
| | - Claudia Wolff
- Medtronic International Trading Sàrl, Route du Molliau 31, 1131 Tolochenaz, Switzerland
| | - Emmanuelle Nicolle
- Medtronic International Trading Sàrl, Route du Molliau 31, 1131 Tolochenaz, Switzerland
| | | | - Andreas Götte
- St. Vincenz Hospital Paderborn, Dept of Cardiology & Intensive Care Medicine, Am Busdorf 2, 33098 Paderborn, Germany
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33
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Clarke A, Ravani P, Oliver MJ, Hiremath S, Blake PG, Moist LM, Garg AX, Lam NN, Quinn RR. Timing of Fistula Creation and the Probability of Catheter-Free Use: A Cohort Study. Can J Kidney Health Dis 2019; 6:2054358119843139. [PMID: 31105964 PMCID: PMC6506926 DOI: 10.1177/2054358119843139] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 02/15/2019] [Indexed: 11/16/2022] Open
Abstract
Background: Fistula creation is recommended to avoid the use of central venous catheters
for hemodialysis. The extent to which timing of fistula creation minimizes
catheter use is unclear. Objective: To compare patient outcomes of 2 fistula creation strategies: fistula attempt
prior to the initiation of dialysis (“predialysis”) or fistula attempt after
starting dialysis (“postinitiation”). Design: Cohort study. Setting: Five Canadian dialysis programs. Patients: Patients who started hemodialysis between 2004 and 2012, who underwent
fistula creation, and were tracked in the Dialysis Measurement Analysis and
Reporting (DMAR) system. Measurements: Catheter-free fistula use within 1 year of hemodialysis start, probability of
catheter-free fistula use during follow-up, and rates of access-related
procedures. Methods: Retrospective data analysis: logistic regression; negative binomial
regression. Results: Five hundred and eight patients had fistula attempts predialysis and 583
postinitiation. At 1 year, 80% of those with predialysis attempts achieved
catheter-free use compared to 45% with post-initiation attempts (adjusted
odds ratio [OR]preVSpost = 4.67; 95% confidence interval [CI] =
3.28-6.66). The average of all patient follow-up time spent catheter-free
was 63% and 28%, respectively (probability of use per unit time,
ORpreVSpost = 2.90; 95% CI = 2.18-3.85). This finding was
attenuated when accounting for maturation time and when restricting the
analysis to those who achieved catheter-free use. Predialysis fistula
attempts were associated with lower procedure rates after dialysis
initiation—1.61 procedures per person-year compared with 2.55—but had 0.65
more procedures per person prior to starting dialysis. Limitations: Observational design, unknown indication for predialysis and postinitiation
fistula creation, and unknown reasons for prolonged catheter use. Conclusions: Predialysis fistula attempts were associated with a higher probability of
catheter-free use and remaining catheter-free over time, and also resulted
in fewer procedures compared with postinitiation attempts, which could be
due to timing of attempt or patient factors. Catheter use and procedures
were still common for all patients, regardless of the timing of fistula
creation.
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Affiliation(s)
- Alix Clarke
- Department of Medicine, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Pietro Ravani
- Department of Medicine, Cumming School of Medicine, University of Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Matthew J Oliver
- Division of Nephrology, Department of Medicine, University of Toronto, ON, Canada
| | - Swapnil Hiremath
- Division of Nephrology, Department of Medicine and Kidney Research Centre, Ottawa Hospital Research Institute, The University of Ottawa, ON, Canada
| | - Peter G Blake
- Kidney Clinical Research Unit, London Health Sciences Centre, ON, Canada.,Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
| | - Louise M Moist
- Kidney Clinical Research Unit, London Health Sciences Centre, ON, Canada.,Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
| | - Amit X Garg
- Kidney Clinical Research Unit, London Health Sciences Centre, ON, Canada.,Division of Nephrology, Department of Medicine, Western University, London, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Ngan N Lam
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Robert R Quinn
- Department of Medicine, Cumming School of Medicine, University of Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, AB, Canada
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34
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Subramanian L, Zhao J, Zee J, Knaus M, Fagerlin A, Perry E, Swartz J, McCall M, Bryant N, Tentori F. Use of a Decision Aid for Patients Considering Peritoneal Dialysis and In-Center Hemodialysis: A Randomized Controlled Trial. Am J Kidney Dis 2019; 74:351-360. [PMID: 30954312 DOI: 10.1053/j.ajkd.2019.01.030] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 01/29/2019] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Annually, about 100,000 US patients face the difficult choice between the most common dialysis types, in-center hemodialysis and peritoneal dialysis. This study evaluated the value of a new decision aid to assist in the choice of dialysis modality. STUDY DESIGN A parallel-group randomized controlled trial to test the efficacy of the decision aid on decision-making outcomes. SETTING & PARTICIPANTS English-speaking US adults with advanced chronic kidney disease and internet access enrolled in 2015. INTERVENTION Participants randomly assigned to the decision aid intervention received information about chronic kidney disease, peritoneal dialysis, and hemodialysis and a value clarification exercise through the study website using their own electronic devices. Participants in the control arm were only required to complete the control questionnaire. Questionnaire responses were used to assess differences across arms in decision-making outcomes. OUTCOMES Treatment preference, decisional conflict, decision self-efficacy, knowledge, and preparation for decision making. RESULTS Of 234 consented participants, 94 (40.2%) were lost to follow-up before starting the study. Among the 140 (70 in each arm) who started the study, 7 were subsequently lost to follow-up. Decision aid users had lower decisional conflict scores (42.5 vs 29.1; P<0.001) and higher average knowledge scores (90.3 vs 76.5; P<0.001). Both arms had high decisional self-efficacy scores independent of decision aid use. Uncertainty about choice of dialysis treatment declined from 46% to 16% after using the decision aid. Almost all (>90%) users of the decision aid reported that it helped in decision making. LIMITATIONS Limited generalizability from the study of self-selected study participants who had to have internet access, speak English, and have computer literacy. High postrandomization loss to follow-up. Evaluation of only short-term outcomes. CONCLUSIONS The decision aid improves decision-making outcomes immediately after use. Implementation of the decision aid in clinical practice may allow further assessment of its effects on patient engagement and empowerment in choosing a dialysis modality. FUNDING This study was funded through a Patient Centered Outcomes Research Institute (PCORI) award (#1109). TRIAL REGISTRATION Registered at ClinicalTrials.gov with study number NCT02488317.
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Affiliation(s)
| | - Junhui Zhao
- Arbor Research Collaborative for Health, Ann Arbor, MI
| | - Jarcy Zee
- Arbor Research Collaborative for Health, Ann Arbor, MI.
| | - Megan Knaus
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI
| | - Angela Fagerlin
- University of Utah, Salt Lake City, UT; Salt Lake City VA Center for Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation, Salt Lake City, UT
| | - Erica Perry
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI
| | | | | | | | - Francesca Tentori
- Vanderbilt University, Nashville, TN; Davita Clinical Research, Minneapolis, MN
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35
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Incremental dialysis in ESRD: systematic review and meta-analysis. J Nephrol 2019; 32:823-836. [DOI: 10.1007/s40620-018-00577-9] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Accepted: 12/18/2018] [Indexed: 12/15/2022]
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36
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Wang V, Coffman CJ, Sanders LL, Lee SYD, Hirth RA, Maciejewski ML. Medicare's New Prospective Payment System on Facility Provision of Peritoneal Dialysis. Clin J Am Soc Nephrol 2018; 13:1833-1841. [PMID: 30455323 PMCID: PMC6302340 DOI: 10.2215/cjn.05680518] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Accepted: 08/31/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Peritoneal dialysis is a self-administered, home-based treatment for ESKD associated with equivalent mortality, higher quality of life, and lower costs compared with hemodialysis. In 2011, Medicare implemented a comprehensive prospective payment system that makes a single payment for all dialysis, medication, and ancillary services. We examined whether the prospective payment system increased dialysis facility provision of peritoneal dialysis services and whether changes in peritoneal dialysis provision were more common among dialysis facilities that are chain affiliated, located in nonurban areas, and in regions with high dialysis market competition. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a longitudinal retrospective cohort study of n=6433 United States nonfederal dialysis facilities before (2006-2010) and after (2011-2013) the prospective payment system using data from the US Renal Data System, Medicare, and Area Health Resource Files. The outcomes of interest were a dichotomous indicator of peritoneal dialysis service availability and a discrete count variable of dialysis facility peritoneal dialysis program size defined as the annual number of patients on peritoneal dialysis in a facility. We used general estimating equation models to examine changes in peritoneal dialysis service offerings and peritoneal dialysis program size by a pre- versus post-prospective payment system effect and whether changes differed by chain affiliation, urban location, facility size, or market competition, adjusting for 1-year lagged facility-, patient with ESKD-, and region-level demographic characteristics. RESULTS We found a modest increase in observed facility provision of peritoneal dialysis and peritoneal dialysis program size after the prospective payment system (36% and 5.7 patients in 2006 to 42% and 6.9 patients in 2013, respectively). There was a positive association of the prospective payment system with peritoneal dialysis provision (odds ratio, 1.20; 95% confidence interval, 1.13 to 1.18) and PD program size (incidence rate ratio, 1.27; 95% confidence interval, 1.22 to 1.33). Post-prospective payment system change in peritoneal dialysis provision was greater among nonurban (P<0.001), chain-affiliated (P=0.002), and larger-sized facilities (P<0.001), and there were higher rates of peritoneal dialysis program size growth in nonurban facilities (P<0.001). CONCLUSIONS Medicare's 2011 prospective payment system was associated with more facilities' availability of peritoneal dialysis and modest growth in facility peritoneal dialysis program size. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2018_11_19_CJASNPodcast_18_12_.mp3.
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Affiliation(s)
- Virginia Wang
- Departments of Population Health Sciences and
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Health Services Research and Development Center of Innovation, Durham Veterans Affairs Health Care System, Durham, North Carolina; and
| | - Cynthia J. Coffman
- Biostatistics and Bioinformatics and
- Health Services Research and Development Center of Innovation, Durham Veterans Affairs Health Care System, Durham, North Carolina; and
| | - Linda L. Sanders
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Shoou-Yih D. Lee
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan
| | - Richard A. Hirth
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan
| | - Matthew L. Maciejewski
- Departments of Population Health Sciences and
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Health Services Research and Development Center of Innovation, Durham Veterans Affairs Health Care System, Durham, North Carolina; and
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37
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Rottembourg J, Rostoker G. La réalité de la dialyse péritonéale en France : 40 ans après. Nephrol Ther 2018; 14:507-517. [DOI: 10.1016/j.nephro.2018.02.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 02/03/2018] [Accepted: 02/18/2018] [Indexed: 02/06/2023]
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38
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Selby NM, Kazmi I. Peritoneal dialysis has optimal intradialytic hemodynamics and preserves residual renal function: Why isn't it better than hemodialysis? Semin Dial 2018; 32:3-8. [PMID: 30352482 DOI: 10.1111/sdi.12752] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Rates of cardiovascular mortality are disproportionately high in patients with end stage kidney disease receiving dialysis. However, it is now generally accepted that patient survival is broadly equivalent between the two most frequently used forms of dialysis, in-center hemodialysis (HD) and peritoneal dialysis (PD). This equivalent patient survival is notable when considering how specific aspects of HD have been shown to contribute to morbidity and mortality. These include more rapid loss of residual renal function (RRF), HD-induced myocardial and cerebral ischemia, and risk factors associated with the intermittent delivery of HD. Potential mechanisms specific to PD that may drive cardiovascular disease include the metabolic consequences of excessive absorption of glucose and glucose degradation products (GDPs), inadequate volume control, and high rates of hypokalemia. The aim of this review is to compare and contrast the different drivers of adverse outcomes between the dialysis modalities, as greater understanding of this may help in patient-centered decision-making when considering options for renal replacement therapy.
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Affiliation(s)
- Nicholas M Selby
- Centre for Kidney Research and Innovation, School of Medicine, University of Nottingham, Nottingham, UK.,Department of Renal Medicine, Royal Derby Hospital, Derby, UK
| | - Isma Kazmi
- Centre for Kidney Research and Innovation, School of Medicine, University of Nottingham, Nottingham, UK.,Department of Renal Medicine, Royal Derby Hospital, Derby, UK
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39
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Zhou H, Sim JJ, Bhandari SK, Shaw SF, Shi J, Rasgon SA, Kovesdy CP, Kalantar-Zadeh K, Kanter MH, Jacobsen SJ. Early Mortality Among Peritoneal Dialysis and Hemodialysis Patients Who Transitioned With an Optimal Outpatient Start. Kidney Int Rep 2018; 4:275-284. [PMID: 30775624 PMCID: PMC6365351 DOI: 10.1016/j.ekir.2018.10.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 09/26/2018] [Accepted: 10/08/2018] [Indexed: 12/23/2022] Open
Abstract
Introduction Lower early mortality observed in peritoneal dialysis (PD) compared with hemodialysis (HD) may be due to differential pre–end-stage renal disease (ESRD) care and the stable setting of transition to dialysis where PD starts are more frequently outpatient rather than during an unscheduled hospitalization. To account for these circumstances, we compared early mortality among a matched cohort of PD and HD patients who had optimal and outpatient starts. Methods Retrospective cohort study performed among patients with chronic kidney disease (CKD) who transitioned to ESRD from 1 January 2002 to 31 March 2015 with an optimal start in an outpatient setting. Optimal start defined as (i) HD with an arteriovenous graft or fistula or (ii) PD. Propensity score modeling factoring age, race, sex, comorbidities, estimated glomerular filtration rate (eGFR) level, and change in eGFR before ESRD was used to create a matched cohort of HD and PD. All-cause mortality was compared at 6 months, 1 year, and 2 years posttransition to ESRD. Results Among 2094 patients (1398 HD and 696 PD) who had optimal outpatient transition to ESRD, 541 HD patients were propensity score–matched to 541 PD patients (caliper distance <0.001). All-cause mortality odds ratios (OR) in PD compared with HD were 0.79 (0.39–1.63), 0.73 (0.43–1.23), and 0.88 (0.62–1.26) for 6 months, 1 year, and 2 years, respectively. Time-varying analysis accounting for modality switch (19% PD, 1.9% HD) demonstrated a mortality hazard ratio of 0.94 (0.70–1.24) Conclusion Among an optimal start CKD cohort that transitioned to ESRD on an outpatient basis, we found no evidence of differences in early mortality between PD and HD.
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Affiliation(s)
- Hui Zhou
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - John J Sim
- Division of Nephrology and Hypertension, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
| | - Simran K Bhandari
- Division of Nephrology and Hypertension, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
| | - Sally F Shaw
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Jiaxiao Shi
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Scott A Rasgon
- Division of Nephrology and Hypertension, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, University of California Irvine Medical Center, Irvine, California, USA
| | - Michael H Kanter
- Regional Quality and Clinical Analysis, Southern California Permanente Medical Group, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Steven J Jacobsen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
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40
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Maddux DW, Usvyat LA, Blanchard T, Jiao Y, Kotanko P, van der Sande FM, Kooman JP, Maddux FW. TRANSITION PERIOD CLINICAL TRAJECTORIES FOR PD VERSUS HD STARTERS. Perit Dial Int 2018; 39:42-50. [PMID: 30257998 DOI: 10.3747/pdi.2017.00252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 05/29/2018] [Accepted: 06/02/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Peritoneal dialysis (PD) starters generally have a better outcome compared with hemodialysis (HD) starters, perhaps related to treatment characteristics or case mix. We previously showed that pre- and post-dialysis start clinical parameter trajectories are related to outcomes. The aim of this study was to investigate these trajectories in PD and HD starters. METHODS This retrospective observational study analyzing data from the Fresenius Medical Care-chronic kidney disease (CKD) Registry from January 2009 to March 2018 examines trends in key clinical parameters through the transition period covering 12 months before to 12 months after dialysis start in 8,088 HD and 1,015 PD starters. RESULTS Hemodialysis starters differed from PD starters by a significantly greater decline in estimated glomerular filtration rate (eGFR) slope (-0.64 vs -0.45 mL/min/1.73 m2/month) before and higher eGFR (9.85 vs 7.84 mL/min/1.73 m2) at dialysis start. Relatedly, differences in phosphorus (0.07 vs 0.05 mg/dL/month) and hemoglobin (-0.08 vs -0.01 g/dL/month) slopes before the transition to dialysis therapy were observed. After dialysis start, HD starters experienced a greater increase in albumin (0.01 vs 0 g/dL/month) whereas PD starters experienced a decline in serum sodium and higher white blood cell counts compared with HD starters. CONCLUSION For nephrology practice CKD patients, HD and PD starters appear clinically comparable in the year before dialysis start although HD starters exhibit a more rapid pre-dialytic eGFR decline. Ideally, studies comparing incident HD and PD outcomes should also consider CKD eGFR trajectories. In the first dialysis year, divergence occurs in albumin, white blood cell count, sodium and hemoglobin trends, which may be partly treatment-related.
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Affiliation(s)
- Dugan W Maddux
- Medical Office, Fresenius Medical Care North America, Waltham, United States
| | - Len A Usvyat
- Medical Office, Fresenius Medical Care North America, Waltham, United States
| | - Thomas Blanchard
- Medical Office, Fresenius Medical Care North America, Waltham, United States
| | - Yue Jiao
- Medical Office, Fresenius Medical Care North America, Waltham, United States
| | - Peter Kotanko
- Nephrology, Renal Research Institute, NY, United States
| | - Frank M van der Sande
- Internal Medicine and Nephrology , Maastricht University Medical Center, Maastricht, Netherlands
| | | | - Franklin W Maddux
- Medical Office, Fresenius Medical Care North America, Waltham, United States
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41
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Piccoli GB, Cabiddu G, Moio MR, Fois A, Cao R, Molfino I, Kaniassi A, Lippi F, Froger L, Pani A, Biolcati M. Efficiency and nutritional parameters in an elderly high risk population on hemodialysis and hemodiafiltration in Italy and France: different treatments with similar names? BMC Nephrol 2018; 19:171. [PMID: 29986663 PMCID: PMC6038182 DOI: 10.1186/s12882-018-0948-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 06/14/2018] [Indexed: 12/29/2022] Open
Abstract
Background Choice of dialysis is context sensitive, explored for PD and extracorporeal dialysis, but less studied for haemodialysis (HD) and hemodiafiltration (HDF), both widely employed in Italy and France; reasons of choice and differences in prescriptions may impact on dialysis-related variables, particularly relevant in elderly, high-comorbidity patients. Methods The study involved two high-comorbidity in-hospital cohorts, treated in Centers with similar characteristics, in Italy (Cagliari) and France (Le Mans). All patients (204) agreed to participate. Stable cases on thrice-weekly dialysis, with at least 2 months follow-up were selected (180 patients, Males 59.4%, median age 71 years, vintage 4.3 years, Charlson index 9). Univariate and multivariate correlations between baseline data, HD-HDF, dialysis efficiency and nutritional markers were assessed. Results In Le Mans HDF was mainly chosen to increase efficiency (large surface dialysers, high convective volume; 76.3% of the patients), in Cagliari to improve tolerance (smaller surfaces, lower convective volume; 59% of patients). Kt/V was similar in HD and HDF, and in both settings(median Kt/V Daugirdas 2: 1.6); in the setting of high efficiency no correlation was found between Kt/V, BMI, urea, creatinine, n-PCR and phosphate. The relationship between Kt/V and albumin was divergent: a weak consensual increase was present in Cagliari, a decrease in Le Mans, suggesting a role of albumin losses with high convective volumes. In the multivariate analysis, after adjustment for other covariates (including comorbidity and type of treatment) low albumin level < 3.5 g/dl was highly correlated with setting of study: Le Mans (OR: 7.155 (2.955–17.324)). The multivariate analysis confirmed a role of type of treatment, with higher risk of low albumin levels in HDF (OR: 3.592 (1.466–8.801)), and of comorbidity (Charlson index> = 7 (OR: 3.153 (1.311–7.582)), MIS index> = 7 (OR: 5.916 (2.457–14.241)). Conclusions The different prescriptions of HD and HDF may have similar effects on dialysis efficiency, but diverging effects on crucial nutritional markers, such as albumin levels, probably more evident in high-comorbidity populations.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Dipartimento di Scienze Cliniche e Biologiche, Università di Torino, Torino, Italy. .,Nephrologie, Centre Hospitalier Le Mans, Avenue Roubillard 182, 7200, Le Mans, France.
| | | | - Maria Rita Moio
- Nephrologie, Centre Hospitalier Le Mans, Avenue Roubillard 182, 7200, Le Mans, France
| | | | | | - Ida Molfino
- Nephrologie, Centre Hospitalier Le Mans, Avenue Roubillard 182, 7200, Le Mans, France.,University of Naples, Naples, Italy
| | - Ana Kaniassi
- Nutrition Clinique, Centre Hospitalier Le Mans, 7200, Le Mans, France
| | - Francoise Lippi
- Nutrition Clinique, Centre Hospitalier Le Mans, 7200, Le Mans, France
| | - Ludivine Froger
- Nutrition Clinique, Centre Hospitalier Le Mans, 7200, Le Mans, France
| | | | - Marilisa Biolcati
- Obstetrics, Department of Surgery, University of Torino, Torino, Italy
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Obi Y, Streja E, Mehrotra R, Rivara MB, Rhee CM, Soohoo M, Gillen DL, Lau WL, Kovesdy CP, Kalantar-Zadeh K. Impact of Obesity on Modality Longevity, Residual Kidney Function, Peritonitis, and Survival Among Incident Peritoneal Dialysis Patients. Am J Kidney Dis 2018; 71:802-813. [PMID: 29223620 PMCID: PMC5970950 DOI: 10.1053/j.ajkd.2017.09.010] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 09/07/2017] [Indexed: 11/11/2022]
Abstract
BACKGROUND The prevalence of severe obesity, often considered a contraindication to peritoneal dialysis (PD), has increased over time. However, mortality has decreased more rapidly in the PD population than the hemodialysis (HD) population in the United States. The association between obesity and clinical outcomes among patients with end-stage kidney disease remains unclear in the current era. STUDY DESIGN Historical cohort study. SETTING & PARTICIPANTS 15,573 incident PD patients from a large US dialysis organization (2007-2011). PREDICTOR Body mass index (BMI). OUTCOMES Modality longevity, residual renal creatinine clearance, peritonitis, and survival. RESULTS Higher BMI was significantly associated with shorter time to transfer to HD therapy (P for trend < 0.001), longer time to kidney transplantation (P for trend < 0.001), and, with borderline significance, more frequent peritonitis-related hospitalization (P for trend = 0.05). Compared with lean patients, obese patients had faster declines in residual kidney function (P for trend < 0.001) and consistently achieved lower total Kt/V over time (P for trend < 0.001) despite greater increases in dialysis Kt/V (P for trend < 0.001). There was a U-shaped association between BMI and mortality, with the greatest survival associated with the BMI range of 30 to < 35kg/m2 in the case-mix adjusted model. Compared with matched HD patients, PD patients had lower mortality in the BMI categories of < 25 and 25 to < 35kg/m2 and had equivalent survival in the BMI category ≥ 35kg/m2 (P for interaction = 0.001 [vs < 25 kg/m2]). This attenuation in survival difference among patients with severe obesity was observed only in patients with diabetes, but not those without diabetes. LIMITATIONS Inability to evaluate causal associations. Potential indication bias. CONCLUSIONS Whereas obese PD patients had higher risk for complications than nonobese PD patients, their survival was no worse than matched HD patients.
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Affiliation(s)
- Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA
| | - Rajnish Mehrotra
- Kidney Research Institute and Harborview Medical Center, Division of Nephrology, University of Washington, Seattle, WA
| | - Matthew B Rivara
- Kidney Research Institute and Harborview Medical Center, Division of Nephrology, University of Washington, Seattle, WA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA
| | - Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA
| | - Daniel L Gillen
- Department of Statistics, University of California Irvine, School of Medicine, Orange, CA
| | - Wei-Ling Lau
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN; Nephrology Section, Memphis VA Medical Center, Memphis, TN
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA; Fielding School of Public Health at UCLA, Los Angeles, CA; Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA.
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43
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Affiliation(s)
- Emilie Trinh
- Division of Nephrology; McGill University Health Center; Montreal QC Canada
| | | | - Jeffrey Perl
- Division of Nephrology; St. Michael's Hospital and the Keenan Research Center in the Li Ka Shing Knowledge Institute; St. Michael's Hospital; Toronto ON Canada
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44
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Jaar BG, Choi MJ. An Introduction to dialysis education: Issues, innovations and impact. Semin Dial 2018; 31:99-101. [PMID: 29509328 DOI: 10.1111/sdi.12680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Bernard G Jaar
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Nephrology Center of Maryland, Baltimore, MD, USA
| | - Michael J Choi
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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45
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Wong B, Ravani P, Oliver MJ, Holroyd-Leduc J, Venturato L, Garg AX, Quinn RR. Comparison of Patient Survival Between Hemodialysis and Peritoneal Dialysis Among Patients Eligible for Both Modalities. Am J Kidney Dis 2017; 71:344-351. [PMID: 29174322 DOI: 10.1053/j.ajkd.2017.08.028] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Accepted: 08/27/2017] [Indexed: 11/11/2022]
Abstract
BACKGROUND Although peritoneal dialysis (PD) costs less to the health care system compared to in-center hemodialysis (HD), it is an underused therapy. Neither modality has been consistently shown to confer a clear benefit to patient survival. A key limitation of prior research is that study patients were not restricted to those eligible for both therapies. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS All adult patients developing end-stage renal disease from January 2004 to December 2013 at any of 7 regional dialysis centers in Ontario, Canada, who had received at least 1 outpatient dialysis treatment and had completed a multidisciplinary modality assessment. PREDICTOR HD or PD. OUTCOMES Mortality from any cause. RESULTS Among all incident patients with end-stage renal disease (1,579 HD and 453 PD), PD was associated with lower risk for death among patients younger than 65 years. However, after excluding approximately one-third of all incident patients deemed to be ineligible for PD, the modalities were associated with similar survival regardless of age. This finding was also observed in analyses that were restricted to patients initiating dialysis therapy electively as outpatients. The impact of modality on survival did not vary over time. LIMITATIONS The determination of PD eligibility was based on the judgment of the multidisciplinary team at each dialysis center. CONCLUSIONS HD and PD are associated with similar mortality among incident dialysis patients who are eligible for both modalities. The effect of modality on survival does not appear to change over time. Future comparisons of dialysis modality should be restricted to individuals who are deemed eligible for both modalities to reflect the outcomes of patients who have the opportunity to choose between HD and PD in clinical practice.
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Affiliation(s)
- Ben Wong
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, Headwaters Health Care Center, Orangeville, Ontario, Canada.
| | - Pietro Ravani
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew J Oliver
- Department of Medicine, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Jayna Holroyd-Leduc
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Amit X Garg
- Department of Medicine, Western University, London, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Robert R Quinn
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Rebollo Rubio A, Morales Asencio JM, Pons Raventos ME. Biomarkers associated with mortality in patients undergoing dialysis. J Ren Care 2017; 43:163-174. [DOI: 10.1111/jorc.12205] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Ana Rebollo Rubio
- Nephrology Service; Carlos Haya Regional University Hospital; Malaga Spain
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47
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Hogan J, Ranchin B, Fila M, Harambat J, Krid S, Vrillon I, Roussey G, Fischbach M, Couchoud C. Effect of center practices on the choice of the first dialysis modality for children and young adults. Pediatr Nephrol 2017; 32:659-667. [PMID: 27844146 DOI: 10.1007/s00467-016-3538-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 10/06/2016] [Accepted: 10/07/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Peritoneal dialysis (PD) remains the modality of choice in children, but there is no clear evidence to support a better outcome in children treated with PD. We aimed to assess factors that have an impact on the choice of dialysis modality in children and young adults in France and sought to determine the roles of medical factors and center practices. METHODS We included all patients aged <20 years at the start of renal replacement therapy (RRT), recorded in the French RRT Registry between 2002 and 2013. Hierarchical logistic regression models were used to study the association between the patient/center characteristics and the probability of receiving PD as the first dialysis modality. RESULTS We included 806 patients starting RRT in 177 centers, 23 of which were specialized pediatric centers. Six hundred and one patients (74.6 %) started with hemodialysis (HD), whereas 205 (25.4 %) started with PD. A greater probability of PD was found in younger children, whereas starting the treatment in an emergency setting was associated with a low use of PD. We found a significant variability among centers that accounted for 43 % of the total variability. The probability of PD was higher in adult centers and was proportional to the rate of PD in the center. CONCLUSIONS Center practices are a major factor in the choice of dialysis modality. This raises concerns about patient and family choices and to what extent doctors may influence the final decision. Further pediatric studies focusing on children's and parents' wishes are needed to provide care as close as possible to patients' and families' expectations.
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Affiliation(s)
- Julien Hogan
- Pediatric Nephrology Unit, Robert Debré Hospital APHP, 48 bld Serurier, 75019, Paris, France. .,REIN Registry, Agence de la biomédecine, Saint-Denis, La Plaine, France.
| | - Bruno Ranchin
- Pediatric Nephrology Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
| | - Marc Fila
- Pediatric Nephrology Unit, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Jérome Harambat
- Pediatric Nephrology Unit, Bordeaux University Hospital, Bordeaux, France
| | - Saoussen Krid
- Pediatric Nephrology Unit, Necker Hospital, Paris, France
| | - Isabelle Vrillon
- Pediatric Nephrology Unit, Hôpital d'Enfants Brabois, Nancy, France
| | - Gwenaelle Roussey
- Pediatric Nephrology Unit, Nantes University Hospital, Nantes, France
| | - Michel Fischbach
- Pediatric Nephrology Unit, Hautepierre University Hospital, Strasbourg, France
| | - Cécile Couchoud
- REIN Registry, Agence de la biomédecine, Saint-Denis, La Plaine, France
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48
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Abstract
Technical innovations in peritoneal dialysis (PD), now used widely for the long-term treatment of ESRD, have significantly reduced therapy-related complications, allowing patients to be maintained on PD for longer periods. Indeed, the survival rate for patients treated with PD is now equivalent to that with in-center hemodialysis. In parallel, changes in public policy have spurred an unprecedented expansion in the use of PD in many parts of the world. Meanwhile, our improved understanding of the molecular mechanisms involved in solute and water transport across the peritoneum and of the pathobiology of structural and functional changes in the peritoneum with long-term PD has provided new targets for improving efficiency and for intervention. As with hemodialysis, almost half of all deaths on PD occur because of cardiovascular events, and there is great interest in identifying modality-specific factors contributing to these events. Notably, tremendous progress has been made in developing interventions that substantially reduce the risk of PD-related peritonitis. Yet the gains have been unequal among individual centers, primarily because of unequal clinical application of knowledge gained from research. The work to date has further highlighted the areas in need of innovation as we continue to strive to improve the health and outcomes of patients treated with PD.
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Affiliation(s)
- Rajnish Mehrotra
- Kidney Research Institute and
- Harborview Medical Center, Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
| | - Olivier Devuyst
- Institute of Physiology, University of Zurich, Zurich, Switzerland
- Division of Nephrology, Université Catholique de Louvain Medical School, Brussels, Belgium
| | - Simon J Davies
- Department of Nephrology, Keele University, Staffordshire, United Kingdom; and
| | - David W Johnson
- Department of Nephrology, Division of Medicine, Princess Alexandra Hospital, University of Queensland, Brisbane, Australia
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49
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Devoe DJ, Wong B, James MT, Ravani P, Oliver MJ, Barnieh L, Roberts DJ, Pauly R, Manns BJ, Kappel J, Quinn RR. Patient Education and Peritoneal Dialysis Modality Selection: A Systematic Review and Meta-analysis. Am J Kidney Dis 2016; 68:422-33. [DOI: 10.1053/j.ajkd.2016.02.053] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 02/22/2016] [Indexed: 11/11/2022]
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50
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[Comparison of peritoneal dialysis and hemodialysis survival in Provence-Alpes-Côte d'Azur]. Nephrol Ther 2016; 12:221-8. [PMID: 27320372 DOI: 10.1016/j.nephro.2016.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 01/05/2016] [Accepted: 01/05/2016] [Indexed: 11/20/2022]
Abstract
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.
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