Patient and physician predictors of peritoneal dialysis technique failure: a population based, retrospective cohort study

Rate and reasons for peritoneal dialysis dropout following haemodialysis to peritoneal dialysis switch: a systematic review and meta-analysis

BACKGROUND

Patient experiences and survival outcomes can be influenced by the circumstances related to dialysis initiation and subsequent modality choices. This systematic review and meta-analysis aimed to explore the rate and reasons for peritoneal dialysis (PD) dropout following haemodialysis (HD) to PD switch.

METHOD

This systematic review conducted searches in four databases, including Medline, PubMed, Embase, and Cochrane. The protocol was registered on PROSPERO (study ID: CRD42023405718). Outcomes included factors leading to the switch from HD to PD, the rate and reasons for PD dropout and mortality difference in two groups (PD first group versus HD to PD group). The Critical Appraisal Skills Programme (CASP) checklist and the GRADE tool were used to assess quality.

RESULTS

4971 papers were detected, and 13 studies were included. On meta-analysis, there was no statistically significant difference in PD dropout in the PD first group (OR: 0.81; 95%CI: 0.61, 1.09; I2 = 83%; P = 0.16), however, there was a statistically significant reduction in the rate of mortality (OR: 0.48; 95%CI: 0.25, 0.92; I2 = 73%; P = 0.03) compared to the HD to PD group. The primary reasons for HD to PD switch, included vascular access failure, patient preference, social issues, and cardiovascular disease. Causes for PD dropout differed between the two groups, but inadequate dialysis and peritonitis were the main reasons for PD dropout in both groups.

CONCLUSION

Compared to the PD first group, a previous HD history may not impact PD dropout rates for patients, but it could impact mortality in the HD to PD group. The reasons for PD dropout differed between the two groups, with no statistical differences. Psychosocial reasons for PD dropout are valuable to further research. Additionally, establishing a consensus on the definition of PD dropout is crucial for future studies.

Nephrologists' perspectives on communication and decision-making regarding technique survival in peritoneal dialysis: an international qualitative interview study

OBJECTIVES

Peritoneal dialysis (PD) allows patients increased autonomy and flexibility; however, both infectious and non-infectious complications may lead to technique failure, which shortens treatment longevity. Maintaining patients on PD remains a major challenge for nephrologists. This study aims to describe nephrologists' perspectives on technique survival in PD.

DESIGN

Qualitative semistructured interview study. Transcripts were thematically analysed.

SETTING AND PARTICIPANTS

30 nephrologists across 11 countries including Australia, the USA, the UK, Hong Kong, Canada, Singapore, Japan, New Zealand, Thailand, Colombia and Uruguay were interviewed from April 2017 to November 2019.

RESULTS

We identified four themes: defining patient suitability (confidence in capacity for self-management, ensuring clinical stability and expected resilience), building endurance (facilitating access to practical support, improving mental well-being, optimising quality of care and training to reduce risk of complications), establishing rapport through effective communications (managing expectations to enhance trust, individualising care and harnessing a multidisciplinary approach) and confronting fear and acknowledging barriers to haemodialysis (preventing crash landing to haemodialysis, facing concerns of losing independence and positive framing of haemodialysis).

CONCLUSION

Nephrologists reported that technique survival in PD is influenced by patients' medical circumstances, psychological motivation and positively influenced by the education and support provided by treating clinicians and families. Strategies to enhance patients' knowledge on PD and communication with patients about technique survival in PD are needed to build trust, set patient expectations of treatment and improve the process of transition off PD.

Outcomes of Integrated Home Dialysis Care: Results From the Canadian Organ Replacement Register

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.

Clinical significance of serum urea-to-creatinine ratio in patients undergoing peritoneal dialysis

INTRODUCTION

We aimed to determine the correlation between the serum urea-to-creatinine ratio and residual kidney function (RKF) in patients undergoing peritoneal dialysis (PD), as well as its predictive value for PD-related outcomes.

METHODS

This study included a cross-sectional study to assess the correlation between serum urea-to-creatinine ratio and RKF in 50 patients on PD and a retrospective cohort study to assess the association between serum urea-to-creatinine ratio and PD-related outcomes in 122 patients who initiated PD.

RESULTS

Serum urea-to-creatinine ratios had significant positive correlations with renal Kt/V and creatinine clearance values (r = 0.60, p < 0.001 and r = 0.61, p < 0.001, respectively). Additionally, serum urea-to-creatinine ratio was significantly associated with a lower risk of transfer to hemodialysis or PD/hemodialysis hybrid therapy (hazard ratio: 0.84, 95% confidence interval: 0.75-0.95).

CONCLUSION

The serum urea-to-creatinine ratio can be an indicator of RKF and a prognostic factor in patients undergoing PD.

The body mass index change is associated with death or hemodialysis transfer in Japanese patients initiating peritoneal dialysis

A decreased body mass index (BMI) over time is associated with a poor prognosis for patients on hemodialysis. We aimed to examine whether this association also applies to patients with peritoneal dialysis (PD). BMI change was defined as the percentage change in the BMI between the time of PD catheter insertion and six months after its insertion. The association between the BMI change and all-cause mortality or PD discontinuation from six months after PD catheter insertion until October 2021 was investigated. This retrospective cohort study included 122 patients (aged 61.1 ± 12.1 years; 90 males) who underwent PD catheter insertion between January 2008 and March 2020. The median follow-up period was 43.1 (21.2-78.8) months. The median six-month percentage change in the BMI was -2.14 (-5.56-1.84)%, and patients were categorized into tertiles based on their BMI changes. The fully-adjusted Cox regression analysis revealed a significantly higher rate of PD discontinuation or all-cause mortality (hazard ratio (HR): 2.48; 95%; confidence interval (CI): 1.41-4.37) in patients with the lowest tertile (T1, BMI change: < -4.13%) compared to patients with the middle tertile (T2, BMI change: -4.13%-0.67%). The risk was not significantly higher in patients with the highest tertile (T3, BMI change: >0.67%) than those in the T2 group (HR: 1.18; 95% CI: 0.66-2.11). A decreased BMI over time is independently associated with HD transfer or all-cause mortality among patients initiating PD, which highlights the importance of the 6-month BMI change as a novel prognostic marker.

Early outcomes of peritoneal dialysis in a middle-income country: A retrospective cohort study of a large dialysis network in Colombia

BACKGROUND

The first year of dialysis is critical given the significant risk for complications following dialysis initiation. We analysed complications during the first year among incident peritoneal dialysis (PD) patients.

METHODS

This retrospective cohort study comprised adult kidney failure patients starting PD in Baxter Renal Care Services in Colombia, receiving their first PD catheter between 1 January 2017 and 31 December 2020 and were followed up for up to 1 year. We analysed incidence, causes and factors associated with complications using logistic regression and transfer to haemodialysis (HD) using the Fine-Gray regression model.

RESULTS

Among 4743 patients receiving their first PD catheter: 4628 (97.6%) of catheter implantations were successful; 377 (7.9%) patients experienced early complications. The incidence rate of complications during the year was 0.51 events per patient-year (95% CI: 0.48-0.54). Age, obesity and urgent start were associated with higher probability of complications after catheter implantation. The cumulative incidence of transfer to HD within 1 year of PD initiation was 10.1% [95% CI: 9.2-11.1%]. The hazard function for transfer to HD showed an accelerating pattern during the first month followed by progressive decrease during the first year.

CONCLUSIONS

In this large population of incident PD patients, there is a high primary catheter placement success rate. Urgent start, age ≥65 years, obesity, centre size ≥150 PD patients and diabetes were risk factors associated with early complications. The follow-up of the cohort from day 1 of PD treatment showed that the risk for transfer to HD was higher during the first month.

Growing a peritoneal dialysis program in Palestine from zero to 178 patients in 5 years: a single-center experience

INTRODUCTION

Kidney failure is rapidly rising in Palestine, as the number of patients receiving maintenance dialysis has quadrupled in the last 15 years. In this study, we share an overview of our experience growing a peritoneal dialysis (PD) program from zero to 178 patients in 5 years at An-Najah National University Hospital in Palestine, presenting some challenges and ways to overcome them.

METHODS

This was a single-center retrospective study of patients treated with PD from November 2016 to December 2021. Demographic and clinical data were obtained for each patient. In addition, PD discontinuation, peritonitis, and mortality rates were calculated and presented as the primary patient outcomes.

RESULTS

A total of 158 patients were eligible for the study. The mean age was 51.8 ± 16.4 years, and 53.8% of patients were male. Diabetic nephropathy was the most common cause of kidney failure. 63 episodes of peritonitis were diagnosed in 48 patients (30.4%) for a rate of 1 episode/ 38.2 patient-months (0.31 episodes/ patient-years). 20 patients had their PD treatment discontinued, mainly due to psychosocial reasons and infectious and mechanical complications. Death was the fate of 27 patients, with cardiovascular disease and COVID-19 being the two main causes.

CONCLUSION

The outcomes of this experience proved favorable and showed that PD could serve as a viable option for kidney failure patients in Palestine. Moreover, this study can serve as an example for other places where circumstances are challenging to take the initiative of starting their PD programs.

High body mass index is a risk factor for transition to hemodialysis or hybrid therapy and peritoneal dialysis-related infection in Japanese patients undergoing peritoneal dialysis

PURPOSE

Obesity may negatively impact the clinical outcomes of patients undergoing peritoneal dialysis (PD). However, the impact of obesity on PD-related outcomes remains unclear. We herein examined the association of high body mass index (BMI) with complete hemodialysis (HD) transfer, transition to HD and PD/HD hybrid therapy, peritonitis, catheter exit-site and tunnel infection (ESI/TI), and heart failure-related hospitalization.

METHODS

This retrospective cohort study included 120 patients who underwent PD-catheter insertion between January 2008 and June 2018. BMI ≥ 25 kg/m² at the time of PD-catheter insertion was defined as high BMI, and its association with outcomes was analyzed using the log-rank test and Cox proportional hazards models.

RESULTS

The follow-up duration was 46.2 (23.3-75.3) months. The time until transfer to HD and hybrid therapy was significantly shorter in the high BMI group than that in the low BMI group, whereas the time until HD transfer was not significantly different between the two groups (P < 0.001 and 0.18, respectively). Peritonitis-free and ESI/TI-free survivals were significantly shorter in the high BMI group than those in the low BMI group (P = 0.006 and 0.03, respectively). After adjusting for age, sex, diabetes mellitus, and estimated glomerular filtration rate, high BMI remained a significant risk factor for transferring to HD and hybrid therapy, peritonitis, and ESI/TI (hazard ratio [HR] 2.60, P < 0.001; HR 2.08, P = 0.01; HR 2.64, P = 0.02, respectively).

CONCLUSION

BMI ≥ 25 kg/m² is a risk factor for transition to HD and hybrid therapy, peritonitis, and ESI/TI, but not for complete HD transfer in Japanese patients with PD.

Incidence and Risk Factors Associated with Technique Failure in the First Year of Peritoneal Dialysis: A Single Center Retrospective Cohort Study in Southern China

Background

Technique failure is more likely to occur during the first 12 months after peritoneal dialysis (PD) initiation, which is a great challenge encountered in PD patients. The aim of this study was to investigate the incidence and risk factors associated with technique failure within the first year of PD patients in Southern China.

Methods

Incident PD patients who were followed up for at least one year at The First Affiliated Hospital of Sun Yat-sen University from January 1, 2006 to December 31, 2015 were included. Technique failure was defined as transferring to hemodialysis (HD) for more than 30 days or death within the first year after start of PD. A competitive risk regression analysis was used to explore the incidence and risk factors of the technique failure.

Results

Overall, 2,290 incident PD patients were included in this study, with a mean age of 48.2 ± 15.7 years, 40.9% female and 25.2% with diabetes. A total of 173 patients (7.5%) had technique failure during the first year of PD. Among them, the patient death account for 62.4% (n = 108) and transferring to HD account for 37.6% (n = 65). The main reasons for death were cardiovascular diseases (n = 32, 29.6%), infection (n = 15, 13.8%) and for conversion to HD were mechanical cause (n = 28, 43.1%), infection cause (n = 22, 33.8%). The risk factors for the technique failure included advanced age (HR 2.78, 95%CI 1.82–4.30), low body mass index (BMI < 18.5 kg/m²: HR 1.77, 95%CI 1.17–2.67), history of congestive heart failure (HR 2.81, 95%CI 1.58–4.98), or time on HD before PD ≤ 3 months (HR 1.49, 95%CI 1.05–2.10), peritonitis (HR 2.02, 95%CI 1.36–3.01);while higher serum albumin (HR 0.93, 95%CI 0.89–0.96) and using employee medical insurance to pay expenses (HR 0.47, 95%CI 0.32–0.69) were associated with reduced risk.

Conclusions

Advanced age, poor nutritional status, history of HD or congestive heart failure, and peritonitis are related factors that increase the risk of technique failure in the first year of PD, while patients' type of medical insurance may also have an influence on early technique failure.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02833-4.

Health-Related Quality of Life Sleep Score Predicts Transfer to Hemodialysis among Patients on Peritoneal Dialysis

Despite the superiority of peritoneal dialysis (PD) over hemodialysis (HD) regarding health-related quality of life (HRQOL), the specific HRQOL domain(s) that predict unplanned HD transfer remains uncertain. In this cohort study, we assessed the HRQOL of 50 outpatients undergoing PD using the Japanese version 1.3 Kidney Disease Quality of Life-Short Form from March 2017 to March 2018 and prospectively analyzed the association of each HRQOL component with HD transfer until June 2021. During the follow-up (41.5 (13.0–50.1) months), 21 patients were transferred to HD. In a multivariate Cox proportional hazards model adjusted for age, sex, PD vintage, urine output, Charlson comorbidity index, and incremental shuttle walking test, a higher sleep score was significantly associated with lower HD transfer rates (HR 0.70 per 10, p = 0.01). An adjusted subdistribution hazard model where elected transition to HD, death, and transplantation were considered competing events of unintended HD transfer that showed sleep score as an exclusive predictor of HD transfer (HR 0.70 per 10, p = 0.002). Our results suggest that sleep score among the HRQOL subscales is instrumental in predicting HD transfer in patients undergoing PD.

Artificial intelligence in peritoneal dialysis: general overview

OBJECTIVE

This article is a general overview about artificial intelligence/machine learning (AI/ML) algorithms in the domain of peritoneal dialysis (PD).

METHODS

We searched studies that used AI/ML in PD, which were classified according to the type of algorithm and PD issue.

RESULTS

Studies were divided into (a) predialytic stratification, (b) peritoneal technique issues, (c) infections, and (d) complications prediction. Most of the studies were observational and majority of them were reported after 2010.

CONCLUSIONS

There is a number of studies proved that AI/ML algorithms can predict better than conventional statistical method and even nephrologists. However, the soundness of AI/ML algorithms in PD still requires large databases and interpretation by clinical experts. In the future, we hope that AI will facilitate the management of PD patients, thus increasing the quality of life and survival.

The availability of support and peritoneal dialysis survival: A cohort study

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 (HR_3-12mo: 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.

Why Peritoneal Dialysis is Underutilized in the United States: A Review of Inequities

Given a choice, most patients with end-stage renal disease prefer home dialysis over in-center hemodialysis (HD). Peritoneal dialysis (PD) is a home dialysis method and offers benefits such as absence of central venous access and therefore preservation of veins, low cost, and decreased time per dialysis session, as well as convenience. Survival rate for patients on PD has increased to levels comparable to in-center HD. Despite endorsement by leaders in the medical field, professional societies, and those in government, PD has reached only 11% adoption among incident patients according to the 2019 United States Renal Data System Annual Data Report. This figure is dwarfed in comparison to rates as high as 79% in other countries. In addition, research has shown that inequities exist in PD access, which are most pronounced in rural, minority, and low-income regions as demonstrated by trends in regional PD supplies. To complicate things further, technique failure has been implicated as a major determinant of poor PD retention rates. The low initiation and retention rates of PD in the United States points to barriers within the healthcare system, many of which are in the early phases of being addressed.

Self-assessment sheet submission rate predicts technique survival in patients initiating peritoneal dialysis

AIM

Patients play a crucial role in preventing peritoneal dialysis (PD)-related events, including peritonitis and fluid overload, as PD procedures are mainly carried out at home. We asked patients to submit a PD self-assessment sheet at each outpatient visit in our daily clinical practice and evaluated its usefulness for outcomes in patients initiating PD.

METHODS

This retrospective cohort study included patients who underwent PD catheter insertion between January 2008 and October 2018. The submission rate of a PD self-assessment sheet was calculated from medical records until PD cessation or study completion (October 2020). The association between the submission rate and technique survival was analysed.

RESULTS

Among the 105 recruited patients (78 men, 60.4 ± 12.2 years), 44 discontinued PD and transferred to haemodialysis during the study period. The follow-up was 52.3 (28.7-79.3) months, and the median submission rate was 78%. The log-rank test showed that technique survival was significantly better in patients with a submission rate ≥ 78% than those with a submission rate < 78% (P = 0.006). The submission rate remained significantly associated with less technique failure (hazard ratio 0.88 per 10%, P = 0.002) by the Cox regression analysis adjusted for age, sex, Charlson comorbidity index, estimated glomerular filtration rate and geriatric nutritional risk index.

CONCLUSION

The submission rate of a PD self-assessment sheet is useful as a predictor of technique survival in patients initiating PD. Instruction that increases submission may improve technique survival in PD patients. This article is protected by copyright. All rights reserved.

Are sex differences in the outcome of peritoneal dialysis explained by nurse-assistance? A cohort study with data from the RDPLF

BACKGROUND

We aimed to evaluate sex differences in peritoneal dialysis (PD) outcomes and to explore direct and indirect effects of nurse-assisted PD on outcomes.

METHODS

This was a retrospective study using data from the French Language Peritoneal Dialysis Registry of incident PD patients between 2005 and 2016. Cox proportional hazard modelling was used to analyse transfer to haemodialysis (HD), death, PD failure, peritonitis and renal transplantation. Mediation analyses with a counterfactual approach were carried out to evaluate natural direct and indirect effects of sex on transfer to HD and peritonitis, with nurse-assisted PD as a mediator a priori.

RESULTS

Of the 14659 patients included, they were 5970 females (41%) and 8689 males (59%). Women were more frequently treated by nurse-assisted PD than men ((2926/5970 (49.1%) vs. 3357/8689 (38.7%)). In the multivariable analysis, women had a lower risk of transfer to HD (cause-specific hazard ratio(cs-HR): 0.82[95% confidence interval(CI): 0.77-0.88]), death (cs-HR: 0.90[95%CI: 0.85-0.95]), peritonitis (cs-HR: 0.82[95%CI: 0.78-0.87]), PD failure (cs-HR: 0.86[95%CI: 0.83-0.90]) and a lower chance of undergoing transplant (cs-HR: 0.83[95%CI: 0.77-0.90]) than men. There was a direct effect of sex on the risk of transfer to HD (cs-HR: 0.82[95%CI: 0.82-0.83]) with an indirect effect of nurse-assisted PD (cs-HR: 0.97[95%CI: 0.96-0.99]). Nurse-assisted PD had no indirect effect on the risk of peritonitis.

CONCLUSIONS

Our results suggest that compared with men, women have both a lower risk of transfer to HD and peritonitis. Mediation analysis showed that nurse assistance was a potential mediator in the causal pathway between sex and transfer to HD.

Assisted peritoneal dialysis: a feasible KRT modality for frail older patients with end-stage kidney disease (ESKD)

Assisted PD is used as an alternative option for the growing group of frail, older ESKD patients unable to perform their own PD. This study was undertaken to investigate the outcomes of assisted PD in older patients by comparing assisted PD patients with self-care PD patients. This study included all patients aged 70 and above who started on PD in our hospital from 2009 to 2018. Patients were followed up until death, PD cessation or to the end of the study (December 31, 2019). Risk factors associated with mortality, peritonitis and technique failure were evaluated using both cause-specific hazards and subdistribution hazards models. 180 patients were enrolled, including 106 (58.9%) males with a median age of 77.5 (77.2-81.2) years. Among the 180 patients, 62 patients (34.4%) were assisted. Patients on assisted PD group were older, more likely to be female, more prevalent in DM and CVD, with a higher Charlson score than patients undergoing self-care PD (P all < 0.05). In the multivariable analysis, assisted patients had a comparable patient survival and peritonitis-free survival compared to self-care PD patients either in the Cox or in the FG models. According to a Cox model, the use of assisted PD was associated with a lower risk of technique failure (cs-HR 0.20, 95% CI 0.04-0.76), but the association lost its statistical significance in the Fine and Gray model. Our results suggest that assisted PD could be a safe and effective KRT modality for older ESKD patients who need assistance.

Effect of Serum Albumin Changes on Mortality in Patients with Peritoneal Dialysis: A Joint Modeling Approach and Personalized Dynamic Risk Predictions

Peritoneal dialysis (PD) is a frequently used and growing therapy for end-stage renal diseases (ESRD). Survival analysis of PD patients is an ongoing research topic in the field of nephrology. Several biochemical parameters (e.g., serum albumin, creatinine, and blood urea nitrogen) are measured repeatedly in the follow-up period; however, baseline or averaged values are primarily associated with mortality. Although this strategy is not incorrect, it leads to information loss, resulting in erroneous conclusions and biased estimates. This retrospective study used the trajectory of common renal function indexes in PD patients and mainly investigated the association between serum albumin change and mortality. Furthermore, we considered patient-specific variability in serum albumin change and obtained personalized dynamic risk predictions for selected patients at different follow-up thresholds to investigate the effect of serum albumin trajectories on patient-specific mortality. We included 417 patients from the Erciyes University Nephrology Department whose data were retrospectively collected using medical records. A joint modeling approach for longitudinal and survival data was used to investigate the relationship between serum albumin trajectory and mortality of PD patients. Results showed that averaged serum albumin levels were not associated with mortality. However, serum albumin change was significantly and inversely associated with mortality (HR: 2.43, 95% CI: 1.48 to 4.16). Risk of death was positively associated with peritonitis rate, hemodialysis history, and the total number of comorbid and renal diseases with hazard ratios 1.74, 3.21, and 1.41. There was also significant variability between patients. The personalized risk predictions showed that overall survival estimates were not representative for all patients. Using the patient-specific trajectories provided better survival predictions within the follow-up period as more data become available in serum albumin levels. In conclusion, using the trajectory of risk predictors via an appropriate statistical method provided better predictive accuracy and prevented biased findings. We also showed that personalized risk predictions were much informative than overall estimations in the presence of significant patient variability. Furthermore, personalized estimations may play an essential role in monitoring and managing patients during the follow-up period.

Eosinophilic Reaction at the Time of Catheter Insertion Predicts Survival in Patients Initiating Peritoneal Dialysis

INTRODUCTION

Despite excellent biocompatibility, insertion of silicone peritoneal dialysis (PD) catheters can induce minor foreign body reaction, affecting long-term patient outcomes. We evaluated the effect of eosinophilic reaction associated with PD catheter insertion on outcomes of patients initiating PD.

METHODS

Eosinophilic reaction to PD catheter insertion was defined as the ratio of peripheral blood eosinophil count at 1 week after insertion (E1W) to pre-insertion eosinophil count (E0), and the association of E1W/E0 with technique survival, peritonitis-free survival, and heart failure (HF)-related hospitalization-free survival was analyzed.

RESULTS

This retrospective cohort study included 116 patients (89 male patients) who underwent PD catheter insertion between January 2008 and June 2018 (61.3 ± 12.9 years). The follow-up duration was 46.2 (23.8-75.3) months. E1W was significantly higher than E0 (median, 333 vs. 234/μL, p < 0.001), with a median E1W/E0 of 1.54. The log-rank test showed that technique survival, peritonitis-free survival, and HF-related hospitalization-free survival were significantly better in patients with E1W/E0 < 1.54 than in those with E1W/E0 ≥ 1.54 (p = 0.002, <0.001, and <0.001, respectively). By the Cox regression analysis adjusted for age, sex, the Charlson comorbidity index, the estimated glomerular filtration rate, and the geriatric nutritional risk index, E1W/E0 remained a significant risk factor for technique failure, peritonitis, and hospitalization for HF (hazard ratio (HR) 1.68, p = 0.01; HR 2.19, p < 0.001; HR 2.15, p < 0.001, respectively).

CONCLUSION

Eosinophilic reaction at the time of PD catheter insertion is a novel marker that may predict outcomes in patients initiating PD.

Long-term trends in the incidence of peritoneal dialysis-related peritonitis disclose an increasing relevance of streptococcal infections: A longitudinal study

Background

The selective impact of strategies for prevention of PD-related peritonitis (PDrP) may have modified, in the long term, the causal spectrum, clinical presentation and outcomes of these infections.

Objectives

To compare trends in the incidence of PDrP by different microorganisms during a 30-year period, with a particular focus on streptococcal infections. To analyze the clinical presentation and outcomes of these infections. Secondarily, to investigate how the isolation of different species of streptococci can influence the clinical course of PDrP by this genus of bacteria.

Method

Following a retrospective, observational design we investigated 1061 PDrP (1990–2019). We used joinpoint regression analysis to explore trends in the incidence of PDrP by different microorganisms, and compared the risk profile (Cox), clinical presentation and outcomes (logistic regression) of these infections.

Main results

Our data showed a progressive decline in the incidence of PDrP by staphylococci and Gram negative bacteria, while the absolute rates of streptococcal (average annual percent change +1.6%, 95% CI -0.1/+3.2) and polymicrobial (+1.8%, +0.1/+3.5) infections tended to increase, during the same period. Remarkably, streptococci were isolated in 58.6% of polymicrobial infections, and patients who suffered a streptococcal PDrP had a 35.8% chance of presenting at least one other infection by the same genus. The risk profile for streptococcal infections was comparable to that observed for PDrP overall. Streptococcal PDrP were associated with a severe initial inflammatory response, but their clinical course was generally nonaggressive thereafter. We did not observe a differential effect of different groups of streptococci on the clinical presentation or outcome of PDrP.

Conclusions

Time trends in the incidence of PDrP by different microorganisms have granted streptococci an increasing relevance as causative agents of these infections, during the last three decades. This behaviour suggests that current measures of prevention of PDrP may not be sufficiently effective, in the case of this genus of microorganisms.

Four steps to standardize reporting of peritoneal dialysis technique failure: A proposed approach

BACKGROUND

Technique failure is an important outcome measure in research and quality improvement in peritoneal dialysis (PD) programs, but there is a lack of consistency in how it is reported.

METHODS

We used data collected about incident dialysis patients from 10 Canadian dialysis programs between 1 January 2004 and 31 December 2018. We identified four main steps that are required when calculating the risk of technique failure. We changed one variable at a time, and then all steps, simultaneously, to determine the impact on the observed risk of technique failure at 24 months.

RESULTS

A total of 1448 patients received PD. Selecting different cohorts of PD patients changed the observed risk of technique failure at 24 months by 2%. More than one-third of patients who switched to hemodialysis returned to PD-90% returned within 180 days. The use of different time windows of observation for a return to PD resulted in risks of technique failure that differed by 16%. The way in which exit events were handled during the time window impacted the risk of technique failure by 4% and choice of statistical method changed results by 4%. Overall, the observed risk of technique failure at 24 months differed by 20%, simply by applying different approaches to the same data set.

CONCLUSIONS

The approach to reporting technique failure has an important impact on the observed results. We present a robust and transparent methodology to track technique failure over time and to compare performance between programs.

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

Rationale & Objective

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

Study Design

Observational registry-based retrospective cohort study.

Setting & Participants

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

Exposure & Predictors

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

Outcomes

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

Analytical Approach

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

Results

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

Limitations

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

Conclusions

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

Exercise Parameters Predict Technique Survival in Patients on Peritoneal Dialysis

OBJECTIVE

The incremental shuttle walking test (ISWT) is an important marker of aerobic capacity in patients on peritoneal dialysis (PD). This study aimed to evaluate its predictive value for PD-related outcomes.

METHODS

This single-center cohort study recruited outpatients on maintenance PD from our hospital between March 2017 and March 2018. Exercise capacity was assessed using measurement of ISWT and handgrip and quadriceps strength. Patients were divided into 2 groups according to the median of exercise capacity and prospectively followed up until cessation of PD, death, or the study end (October 2019). The primary end point of this study was technique survival rate, and secondary outcomes were rates of peritonitis-free survival and PD-related hospitalization-free survival.

RESULTS

Among the 50 participants, age and PD vintage were [median (IQR)] 62.5 (58.3-70) and 3.5 (1.3-6.5) years, respectively. At the end of the study, 3 of the 28 participants (11%) in the long-ISWT group and 13 of the 22 participants (59%) in the short-ISWT group were transferred to hemodialysis. The short-ISWT group showed lower technique survival rate (p < 0.001), peritonitis-free survival rate (p = 0.01), and PD-related hospitalization-free survival rate (p < 0.01) than the long-ISWT group, whereas those survival rates did not differ when participants were divided by handgrip or quadriceps strength. Multivariate analysis revealed lower ISWT to be independently associated with technique failure (p = 0.002).

CONCLUSION

The ISWT is an important predictor of technique survival for patients on PD. Monitoring and enhancing ISWT as a marker of aerobic capacity might improve PD-related outcomes.

Early technique failure in peritoneal dialysis patients in a multi-ethnic Asian country

PURPOSE

Early technique failure is a serious complication for peritoneal dialysis (PD) patients. The study aimed to examine the incidence, causes, and risk factors associated with early technique failure.   METHODS: This retrospective study included all incident PD patients in a hospital in Singapore from 2013 to 2017. The primary outcome was early technique failure, which was defined as transfer to hemodialysis for ≥ 30 days or death, within the first year of PD initiation. Secondary outcomes were death, technique failure due to PD infection, and death-censored technique failure.

RESULTS

Overall, 517 patients were included in the study. Of these, 98 patients (19.0%) developed early technique failure. The common causes of early technique failure were death (41.8%) and infection (40.8%). Peripheral vascular disease was significantly associated with a higher hazard of early technique failure [hazard ratio (HR) 1.95, 95% confidence interval (CI) 1.04-3.63] and death (HR 3.75, 95% CI 1.71-8.21), whilst glomerulonephritis as a cause of end-stage kidney disease (compared with hypertension) was associated with a lower hazard of early technique failure (HR 0.38, 95% CI 0.18-0.77) and death (HR 0.08, 95% CI 0.02-0.37). Male gender was associated with early technique failure due to PD infection (HR 2.55, 95% CI 1.32-4.95). No specific factor was associated with death-censored early technique failure.

CONCLUSION

Technique failure in the first year of PD initiation occurs in one-fifth of PD patients and is associated with peripheral vascular disease and cause of end-stage kidney disease.

Technique Failure in Peritoneal Dialysis: Etiologies and Risk Assessment

Technique failure (TF) is a well-recognized challenge encountered in patients undergoing peritoneal dialysis (PD). Identification of patients at risk for this complication is of utmost importance. Early detection of patients at risk and development of preventative strategies can improve technique survival that may lead to an increased utilization of PD. It will also promote a safe and planned transfer to hemodialysis once a patient identified with TF. The aim of this review is to summarize risk factors and scenarios associated with TF focusing on prevention of remediable factors at their earliest stage. Furthermore, integration of this knowledge into quality improvement initiatives should be entertained in an effort to improve outcomes.

Early Peritoneal Dialysis Technique Failure: Review

There is a growing, global burden of patients with end-stage kidney disease (ESKD) requiring renal replacement therapy. Although peritoneal dialysis (PD) is considered to be the most cost-effective dialysis modality, its utilization has been declining in some regions. The first year after starting PD is thought to be a vulnerable period for technique failure, which in turn contributes to poor patient retention. Improved understanding of the risk factors for technique failure during this period may help the development of targeted strategies to lower its incidence and improve both the utilization and utility of PD. This up-to-date review will summarize current evidence regarding the definition, incidence, causes, and predictors of early PD technique failure. Promising avenues for directing future research efforts will also be discussed.

The impact of volume overload on technique failure in incident peritoneal dialysis patients

Background

Technique failure in peritoneal dialysis (PD) can be due to patient- and procedure-related factors. With this analysis, we investigated the association of volume overload at the start and during the early phase of PD and technique failure.

Methods

In this observational, international cohort study with longitudinal follow-up of incident PD patients, technique failure was defined as either transfer to haemodialysis or death, and transplantation was considered as a competing risk. We explored parameters at baseline or within the first 6 months and the association with technique failure between 6 and 18 months, using a competing risk model.

Results

Out of 1092 patients of the complete cohort, 719 met specific inclusion and exclusion criteria for this analysis. Being volume overloaded, either at baseline or Month 6, or at both time points, was associated with an increased risk of technique failure compared with the patient group that was euvolaemic at both time points. Undergoing treatment at a centre with a high proportion of PD patients was associated with a lower risk of technique failure.

Conclusions

Volume overload at start of PD and/or at 6 months was associated with a higher risk of technique failure in the subsequent year. The risk was modified by centre characteristics, which varied among regions.

Expanded Prospective Payment System and Use of and Outcomes with Home Dialysis by Race and Ethnicity in the United States

BACKGROUND AND OBJECTIVES

We investigated whether the recent growth in home dialysis use was proportional among all racial/ethnic groups and also whether there were changes in racial/ethnic differences in home dialysis outcomes.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This observational cohort study of US Renal Data System patients initiating dialysis from 2005 to 2013 used logistic regression to estimate racial/ethnic differences in home dialysis initiation over time, and used competing risk models to assess temporal changes in racial/ethnic differences in home dialysis outcomes, specifically: (1) transfer to in-center hemodialysis (HD), (2) mortality, and (3) transplantation.

RESULTS

Of the 523,526 patients initiating dialysis from 2005 to 2013, 55% were white, 28% black, 13% Hispanic, and 4% Asian. In the earliest era (2005-2007), 8.0% of white patients initiated dialysis with home modalities, as did a similar proportion of Asians (9.2%; adjusted odds ratio [aOR], 0.95; 95% confidence interval [95% CI], 0.86 to 1.05), whereas lower proportions of black [5.2%; aOR, 0.71; 95% CI, 0.66 to 0.76] and Hispanic (5.7%; aOR, 0.83; 95% CI, 0.86 to 0.93) patients did so. Over time, home dialysis use increased in all groups and racial/ethnic differences decreased (2011-2013: 10.6% of whites, 8.3% of blacks [aOR, 0.81; 95% CI, 0.77 to 0.85], 9.6% of Hispanics [aOR, 0.94; 95% CI, 0.86 to 1.00], 14.2% of Asians [aOR, 1.04; 95% CI, 0.86 to 1.12]). Compared with white patients, the risk of transferring to in-center HD was higher in blacks, similar in Hispanics, and lower in Asians; these differences remained stable over time. The mortality rate was lower for minority patients than for white patients; this difference increased over time. Transplantation rates were lower for blacks and similar for Hispanics and Asians; over time, the difference in transplantation rates between blacks and Hispanics versus whites increased.

CONCLUSIONS

From 2005 to 2013, as home dialysis use increased, racial/ethnic differences in initiating home dialysis narrowed, without worsening rates of death or transfer to in-center HD in minority patients, as compared with white patients.

Socioeconomic status and mortality among dialysis patients: a systematic review and meta-analysis

BACKGROUND

The reported association between individual indicators of socioeconomic status (SES) and mortality in dialysis patients was inconsistent in previous studies. We performed a meta-analysis to identify the association between SES and mortality of dialysis population.

METHODS

The meta-analysis was conducted in accordance with MOOSE guidelines. Cohorts evaluating the association between SES indicators (income, education and occupation) and mortality in dialysis patients were included. Random-effects models were used to pool the adjusted relative risk (RR) from individual studies. Heterogeneity was assessed by Cochrane's Q and the I² statistic. Subgroup analyses and sensitivity analyses were performed to identify sources of heterogeneity and to evaluate the robustness of findings.

RESULTS

Fourteen studies were finally included. In hemodialysis patients, increased mortality was associated with lower level of income (RR = 1.08, 95%CI [1.01-1.16], P = 0.035; I² = 87.9%, P < 0.001) and occupation (RR = 1.63, 95%CI [1.11-2.38], P = 0.013; I² = 0.0%, P = 0.601). However, no significant association was identified for education (RR = 1.43, 95%CI [0.92-2.25]; P = 0.112; I² = 68.3%,P = 0.001). In patients receiving peritoneal dialysis, lower level of income (RR = 1.80, 95%CI [1.12-2.88],P = 0.015; I² = 75.9%, P = 0.042), education (RR = 1.27, 95%CI [1.13-1.43], P < 0.001; I² = 0.0%, P = 0.684), and occupation (RR = 3.42, 95% CI [1.35-8.70], P = 0.010) were risk factors for increased mortality. Subgroup analysis showed the association between SES indicators and mortality in hemodialysis differed according to geographic locations and study designs.

CONCLUSION

Lower SES (measured by income, education, and occupation) tends to be associated with higher mortality in patients receiving maintenance dialysis. But the magnitude of the associations varied for different individual indicators of SES.

Serum Albumin at Start of Peritoneal Dialysis Predicts Long-Term Outcomes in Anhui Han Patients on Continuous Ambulatory Peritoneal Dialysis: A Retrospective Cohort Study

Objective

This study assessed the relationship between serum albumin (ALB) at start of peritoneal dialysis (PD) and long-term outcomes of continuous ambulatory PD (CAPD) in Anhui Han patients.

Methods

A total of 149 Anhui Han CAPD patients were enrolled in this study and followed up for 3 years. They were initially diagnosed with the end-stage renal disease and underwent surgical PD catheter placement from January 2009 to December 2013. According to serum ALB at start of PD, the patients were divided into two groups: low ALB group (ALB < 35 g/L) and high ALB group (ALB ≥35 g/L). Demographic, hematologic, biochemical, and dialysis-related data were collected. Kaplan-Meier survival analysis and log-rank test were conducted to compare patient mortality, cardiovascular mortality and technique failure between the low ALB group and the high ALB group. Cox regression analysis was performed to analyze the risk factors, calculate the hazard ratio (HR), adjusted HR (AHR) and 95% confidence interval (CI).

Results

The low ALB group showed a greater number of diabetes mellitus compared with the high ALB group. Patient mortality, cardiovascular mortality, and technique failure in the high ALB group were significantly lower than those in the low ALB group. In Cox regression analysis, serum ALB < 35 g/L was an independent predictor of patient mortality (AHR 3.043, 95% CI 1.085-8.536, p = 0.034), cardiovascular mortality (AHR 11.587, 95% CI 1.466-91.574, p = 0.020), and technique failure (AHR 3.148, 95% CI 1.603-6.182, p = 0.001) in CAPD patients after adjustment for sex, age, estimated glomerular filtration rate, primary renal disease, diabetes mellitus, and cardiovascular disease.

Conclusions

In Anhui Han patients on CAPD, the levels of serum ALB at start of PD are inversely correlated with patient mortality, cardiovascular mortality, and technique failure, and the long-term outcomes of patients with hypoalbuminemia at start of PD are poor. To improve the long-term outcomes of Anhui Han CAPD patients, patients with hypoalbuminemia at start of PD should be closely monitored.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Dialysis Access, Infections, and Hospitalisations in Unplanned Dialysis Start Patients: Results from the Options Study

Introduction

Unplanned dialysis start (UPS) associates with worse clinical outcomes, higher utilisation of healthcare resources, lower chances to select dialysis modality and UPS patients typically commenced in-centre haemodialysis (HD) with central venous catheter (CVC). We evaluated patient outcomes and healthcare utilisation depending on initial dialysis access (CVC or PD catheter) and subsequent pathway of UPS patients.

Methods

In this study patient demographics, access procedures, hospitalisations, and major infectious complications were analysed over 12 months in 270 UPS patients. PD technique survival and impact of switching from HD to PD was examined along with logistic regression to investigate factors predicting AV fistula formation.

Results

72 UPS patients started with PD catheter and 198 with CVC. PD patients were older and more comorbid but had a significantly lower number of access procedures while there was no difference in hospitalisation or major infections. 13/72 initial PD patients switched to HD and 1-year technique survival was 79%. 158/198 patients remained on HD and 73/158 reported permanent access formation. Older age, OR = 0.34 (CI, 0.17-0.68) and cardiac failure, OR = 0.31(CI, 0.13–0.78), were significant negative predictors of receiving fistula. Younger patients, OR = 0.29 (CI, 0.11–0.79) and those who received AVF, OR = 0.11 (CI, 0.03–0.38), had significantly lower odds of death.

Discussion

UPS with initial PD was possible in many patients and was associated with lower requirement for access procedures. AVF formation in UPS patients starting on HD was associated with better 1-year survival. Modality switching in UPS patients requires careful clinical management, including clinical practice patterns promoting permanent HD access formation.

Relationship between trajectories of serum albumin levels and technique failure according to diabetic status in peritoneal dialysis patients: A joint modeling approach

Background

In peritoneal dialysis, technique failure is an important metric to be considered. This study was performed in order to identify the relationship between trajectories of serum albumin levels and peritoneal dialysis technique failure on end-stage renal disease patients according to diabetic status. Furthermore, this study was performed to reveal predictors of serum albumin and technique failure simultaneously.

Methods

This retrospective cohort study included 300 (189 non-diabetic and 111 diabetic) end-stage renal disease patients on continuous ambulatory peritoneal dialysis treated in Al-Zahra Hospital, Isfahan, Iran, from May 2005 to March 2015. Bayesian joint modeling was carried out in order to determine the relationship between trajectories of serum albumin levels and peritoneal dialysis technique failure in the patients according to diabetic status. Death from all causes was considered as a competing risk.

Results

Using joint modeling approach, a relationship between trajectories of serum albumin with hazard of transfer to hemodialysis was estimated as −0.720 (95% confidence interval [CI], −0.971 to −0.472) for diabetic and −0.784 (95% CI, −0.963 to −0.587) for non-diabetic patients. From our findings it was showed that predictors of low serum albumin over time were time on peritoneal dialysis for diabetic patients and increase in age and time on peritoneal dialysis, history of previous hemodialysis, and lower body mass index in non-diabetic patients.

Conclusion

The results of current study showed that controlling serum albumin over time in non-diabetic and diabetic patients undergoing continuous ambulatory peritoneal dialysis treatment can decrease risk of adverse outcomes during the peritoneal dialysis period.

Gender-Specific Differences in Peritoneal Dialysis

BACKGROUND/AIMS

Gender-specific differences between patients on renal replacement therapy have so far rarely been investigated. In the present study we aimed to describe gender-specific differences in a large cohort of peritoneal dialysis (PD) patients.

METHODS

Clinical information for all patients who started PD at our center has been collected since the start of the PD-program in 1979. We used Cox regression to examine associations between technique failure and gender. We estimated hazard ratios (HRs) with 95% confidence intervals (CIs).

RESULTS

A total of 745 patients (315 women and 430 men with a median age of 57 years; IQR 43-67) started PD between 1979 and 2015 in our center. Women were significantly younger at PD start 54 (40-65) years vs. 58 (47-68) years, p<0.001. Within the last almost 15 years, more man than women started PD, but technical survival rates were significantly better in female compared to men (HR=0.662, CI 95% (0.496-0.885) P=0.005). Cardiovascular events were the main cause of death over the study period in both sexes, but decreased over time. Additionally, death due to PD-associated peritonitis decreased significantly over the three decades in both sexes.

CONCLUSIONS

Our data suggest that technical survival rates were significantly better in female compared to men over three decades and death due to cardiovascular events and PD-associated peritonitis decreased significantly over the three decades in both sexes.

Prognostic Value of Predialysis Indices for Technique Failure and Mortality in Peritoneal Dialysis Patients

Technique failure remains a frequent cause of peritoneal dialysis (PD) withdrawal. Many post-commencement predictors of PD technique failure have been identified, while predialysis predictors have remained unclear. The aim of this study was to identify predialysis indices for technique failure in PD patients. We recruited 206 consecutive PD patients who were treated at Nara Medical University Hospital between 1 April 1997 and 31 December 2012. Forty-eight patients were excluded because of transition from hemodialysis (HD) or withdrawal from PD within 3 months, leaving 158 patients for analysis. Clinical characteristics and laboratory data from within 3 months preceding PD commencement were analyzed. The primary outcome was the composite of time to combined use of HD, transition to HD, and all-cause mortality within 2 years after PD commencement. During the study period, the primary outcome was observed in 50 patients. Using multivariate analysis, greater age (odds ratios (ORs) [95%CI], 3.08 [1.72-5.61]), anemia (ORs [95%CI], 2.12 [1.08-4.43]), overweight/obesity (ORs [95%CI], 2.09 [1.16-3.72]), and hypocalcemia (ORs [95%CI], 1.86 [1.04-3.35]) were independently associated with technique failure. Adding corrected calcium to the model incorporating age, body mass index, and hemoglobin significantly increased the c-statistic from 0.678 to 0.755 (P = 0.048) relative to the model incorporating age alone. The integrated discrimination improvement was 0.085 (95% CI 0.036-0.134, P < 0.001) and the continuous net reclassification improvement was 0.395 (95% CI 0.066-0.724, P = 0.02). In conclusion, the combination of predialysis indices comprising age, overweight/obesity, anemia, and corrected calcium could provide a significant predictive value for technique failure of PD.

Association of Socio-Economic Position with Technique Failure and Mortality in Australian Non-Indigenous Peritoneal Dialysis Patients

BACKGROUND

Few studies have examined the relationship between socio-economic position (SEP) and peritoneal dialysis (PD) outcomes, particularly at a country level. The aim of this study was to investigate the relationships between SEP, technique failure, and mortality in PD patients undertaking treatment in Australia.

METHODS

The study included all Australian non-indigenous incident PD patients between January 1, 1997, and December 31, 2014, using Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry data. The SEP was assessed by quartiles of postcode-based Australian Socio-Economic Indexes for Areas (SEIFA), including Index of Relative Socio-economic Advantage and Disadvantage (IRSAD - primary index), Index of Relative Socio-economic Disadvantage (IRSD), Index of Economic Resources (IER), and Index of Education and Occupation (IEO). Technique and patient survival were evaluated by multivariable Cox proportional hazards survival analyses.

RESULTS

The study included 9,766 patients (mean age 60.6 ± 15 years, 57% male, 38% diabetic). Using multivariable Cox regression, no significant association was observed between quartiles of IRSAD and technique failure (30-day definition p = 0.65, 180-day definition p = 0.68). Similar results were obtained using competing risks regression. However, higher SEP, defined by quartiles of IRSAD, was associated with better patient survival (Quartile 1 reference; Quartile 2 adjusted hazards ratio [HR] 0.96, 95% confidence interval [CI] 0.86 - 1.06; Quartile 3 HR 0.87, 95% CI 0.77 - 0.99; Quartile 4 HR 0.86, 95% CI 0.76 - 0.97). Similar results were found when IRSD was analyzed, but results were no longer statistically significant for IER and IEO.

CONCLUSIONS

In Australia, where there is universal free healthcare, SEP was not associated with PD technique failure in non-indigenous PD patients. Higher SEP was generally associated with improved patient survival.

Lower Education Level Is a Risk Factor for Peritonitis and Technique Failure but Not a Risk for Overall Mortality in Peritoneal Dialysis under Comprehensive Training System

Background

Lower education level could be a risk factor for higher peritoneal dialysis (PD)-associated peritonitis, potentially resulting in technique failure. This study evaluated the influence of lower education level on the development of peritonitis, technique failure, and overall mortality.

Methods

Patients over 18 years of age who started PD at Seoul National University Hospital between 2000 and 2012 with information on the academic background were enrolled. Patients were divided into three groups: middle school or lower (academic year≤9, n = 102), high school (9<academic year≤12, n = 229), and higher than high school (academic year>12, n = 324). Outcomes were analyzed using Cox proportional hazards models and competing risk regression.

Results

A total of 655 incident PD patients (60.9% male, age 48.4±14.1 years) were analyzed. During follow-up for 41 (interquartile range, 20–65) months, 255 patients (38.9%) experienced more than one episode of peritonitis, 138 patients (21.1%) underwent technique failure, and 78 patients (11.9%) died. After adjustment, middle school or lower education group was an independent risk factor for peritonitis (adjusted hazard ratio [HR], 1.61; 95% confidence interval [CI], 1.10–2.36; P = 0.015) and technique failure (adjusted HR, 1.87; 95% CI, 1.10–3.18; P = 0.038), compared with higher than high school education group. However, lower education was not associated with increased mortality either by as-treated (adjusted HR, 1.11; 95% CI, 0.53–2.33; P = 0.788) or intent-to-treat analysis (P = 0.726).

Conclusions

Although lower education was a significant risk factor for peritonitis and technique failure, it was not associated with increased mortality in PD patients. Comprehensive training and multidisciplinary education may overcome the lower education level in PD.

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

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

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

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

Hospitalization Rates for Patients on Assisted Peritoneal Dialysis Compared with In-Center Hemodialysis

BACKGROUND AND OBJECTIVES

Assisted peritoneal dialysis is a treatment option for individuals with barriers to self-care who wish to receive home dialysis, but previous research suggests that this treatment modality is associated with a higher rate of hospitalization. The objective of our study was to determine whether assisted peritoneal dialysis has a different rate of hospital days compared to in-center hemodialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a multicenter, retrospective cohort study by linking a quality assurance dataset to administrative health data in Ontario, Canada. Subjects were accrued between January 1, 2004 and July 9, 2013. Individuals were grouped into assisted peritoneal dialysis (family or home care assisted) or in-center hemodialysis on the basis of their first outpatient dialysis modality. Inverse probability of treatment weighting using a propensity score was used to create a sample in which the baseline covariates were well balanced.

RESULTS

The study included 872 patients in the in-center hemodialysis group and 203 patients in the assisted peritoneal dialysis group. Using an intention to treat approach, patients on assisted peritoneal dialysis had a similar hospitalization rate of 11.1 d/yr (95% confidence interval, 9.4 to 13.0) compared with 12.9 d/yr (95% confidence interval, 10.3 to 16.1) in the hemodialysis group (P=0.19). Patients on assisted peritoneal dialysis were more likely to be hospitalized for dialysis-related reasons (admitted for 2.4 d/yr [95% confidence interval, 1.8 to 3.2] compared with 1.6 d/yr [95% confidence interval, 1.1 to 2.3] in the hemodialysis group; P=0.04). This difference was partly explained by more hospital days because of peritonitis. Modality switching was associated with high rates of hospital days per year.

CONCLUSIONS

Assisted peritoneal dialysis was associated with similar rates of all-cause hospitalization compared with in-center hemodialysis. Patients on assisted peritoneal dialysis who experienced peritonitis and technique failure had high rates of hospitalization.

Technique failure in Korean incident peritoneal dialysis patients: a national population-based study

Background

Technique failure is an important issue for peritoneal dialysis (PD) patients. In this study, we aimed to analyze technique failure rate in detail and to determine the predictors for technique failure in Korea.

Methods

We identified all patients who had started dialysis between January 1, 2005, and December 31, 2008, in Korea, using the Korean Health Insurance Review and Assessment Service database. A total of 7,614 PD patients were included, and the median follow-up was 24.9 months.

Results

The crude incidence rates of technique failure in PD patients were 54.1 per 1,000 patient-years. The cumulative 1-, 2-, and 3-year technique failure rates of PD patients were 4.9%, 10.3%, and 15.6%, respectively. However, those technique failure rates by Kaplan–Meier analysis were overestimated compared with the values by competing risks analysis, and the differences increased with the follow-up period. In multivariate analyses, diabetes mellitus and Medical Aid as a crude reflection of low socioeconomic status were independent risk factors in both the Cox proportional hazard model and Fine and Gray subdistribution model. In addition, cancer was independently associated with a lower risk of technique failure in the Fine and Gray model.

Conclusion

Technique failure was a major concern in patients initiating PD in Korea, especially in diabetic patients and Medical Aid beneficiaries. The results of our study offer a basis for risk stratification for technique failure.

The Association of Individual and Regional Socioeconomic Status on Initial Peritonitis and Outcomes in Peritoneal Dialysis Patients: A Propensity Score-Matched Cohort Study

♦

BACKGROUND

Research indicates that the socioeconomic status (SES) of individuals and the area where they live are related to initial peritonitis and outcomes in peritoneal dialysis (PD). We conducted a retrospective, multi-center cohort study in China to examine these associations. ♦

METHODS

Data on 2,171 PD patients were collected from 7 centers, including baseline demographic, socioeconomic, and laboratory data. We explored the potential risk factors for initial peritonitis and outcomes using univariate Cox regression and unadjusted binary logistic regression. Then, we used propensity score matching to balance statistically significant risk factors for initial peritonitis and outcomes, and Kaplan-Meier survival analysis to compare differences in peritonitis-free rates between different groups of participants after matching. ♦

RESULTS

A total of 563 (25.9%) initial episodes of peritonitis occurred during the study period. The Kaplan-Meier peritonitis-free rate curve showed high-income patients had a significantly lower risk than low-income patients (p = 0.007) after matching for age, hemoglobin, albumin, and regional SES and PD center. The risk of treatment failure was significantly lower in the high-income than the low-income group after matching for the organism causing peritonitis and PD center: odds ratio (OR) = 0.27 (0.09 - 0.80, p = 0.018). Regional SES and education were not associated with initial peritonitis and outcomes. ♦

CONCLUSIONS

Our study demonstrates low individual income is a risk factor for the initial onset of peritonitis and treatment failure after initial peritonitis.

Peritoneal dialysis use within the context of the population and healthcare systems of Europe - differences, trends and future challenges

INTRODUCTION

Peritoneal dialysis (PD) and haemodialysis (HD) are complementary therapies in end-stage renal disease (ESRD). Despite survival benefit, PD remains an underused therapy with variable utilisation and a common descriptive framework for this variation is not established. We reviewed the renal literature, general population and healthcare data to examine factors leading to variable PD use in Europe and possible changes in the future.

METHODS

ERA-EDTA data were used to examine PD distribution in Europe. Statistics and descriptive data about population structure and living conditions published by Eurostat, the World Health Organization (WHO) and the European Observatory were examined. Published literature (Pubmed), health system data (formal internet search approach) and professional body data (internet and personal communication) were examined to describe the factors that may explain PD variation.

RESULTS

PD usage varies across Europe and analysis of contributing factors enabled the development of a descriptive framework. PD variation cannot be entirely explained by the reimbursement system. It appears that factors specific to countries and centres as well as personalised ones involving patient-physician interaction are the most influential. The current and projected European population demographics and living conditions will lead to more elderly patients who live alone being on dialysis.

DISCUSSION

Factors relating to the patient-physician interaction are prime determinants around the utilization of PD. Population demographic change will lead to additional challenges to renal services. The descriptive framework postulated should be considered in strategic dialysis service planning and future product design to meet the needs of future dialysis patients and deliver patient choice.