Body mass index and mortality risk in Asian peritoneal dialysis patients in Hong Kong-impact of diabetes and cardiovascular disease status

Triglyceride glucose-body mass index and cardiovascular mortality in patients undergoing peritoneal dialysis: a retrospective cohort study

BACKGROUND

Recent studies have shown that triglyceride glucose-body mass index (TyG-BMI) is associated with the risk of ischemic stroke and coronary artery disease. However, little attention has been given to the association between TyG-BMI and cardiovascular disease (CVD) mortality in patients undergoing peritoneal dialysis (PD). Therefore, this study aimed to explore the relationship between TyG-BMI and CVD mortality in southern Chinese patients undergoing PD.

METHODS

Incident patients receiving PD from January 1, 2006, to December 31, 2018, with baseline serum triglyceride, glucose, and body mass index (BMI) information, were recruited for this single-center retrospective cohort study. TyG-BMI was calculated based on fasting plasma glucose, triglyceride, and BMI values. The association between TyG-BMI, CVD and all-cause mortality was evaluated using a multivariate-adjusted Cox proportional hazard regression model.

RESULTS

Of 2,335 patients, the mean age was 46.1 ± 14.8 years; 1,382 (59.2%) were male, and 564 (24.2%) had diabetes. The median TyG-BMI was 183.7 (165.5-209.2). Multivariate linear regression showed that advanced age, male sex, history of CVD, higher levels of albumin and low-density lipoprotein cholesterol, and higher urine output were correlated with a higher TyG-BMI (P < 0.05). During a median follow-up period of 46.6 (22.4-78.0) months, 615 patients died, of whom 297 (48.2%) died as a result of CVD. After adjusting for demographics and comorbidities, TyG-BMI was significantly associated with an increased risk of CVD mortality (hazard ratio [HR] 1.51, 95% confidence interval [CI] 1.05-2.17) and all-cause mortality (HR 1.36, 95% CI 1.05-1.75). After full adjustment, the 28% risk of CVD mortality (HR 1.28, 95% CI 1.13-1.45) and 19% risk of all-cause mortality were elevated (HR 1.19, 95% CI 1.09-1.31) when TyG-BMI increased by 1 stand deviation (SD) (34.2).

CONCLUSIONS

A higher baseline TyG-BMI was independently associated with an increased risk of CVD and all-cause mortality in patients receiving PD.

Urgent Implantation of Peritoneal Dialysis Catheter in Chronic Kidney Disease and Acute Kidney Injury-A Review

Acute kidney injury (AKI) and sudden exacerbation of chronic kidney disease (CKD) frequently necessitate urgent kidney replacement therapy (UKRT). Peritoneal dialysis (PD) is recognized as a viable modality for managing such patients. Urgent-start peritoneal dialysis (USPD) may be associated with an increased number of complications and is rarely utilized. This review examines recent literature investigating the clinical outcomes of USPD in CKD and AKI. Relevant research was identified through searches of the MEDLINE (PubMed), Scopus, Web of Science, and Google Scholar databases using MeSH terms and relevant keywords. Included studies focused on the emergency use of peritoneal dialysis in CKD or AKI and reported treatment outcomes. While no official recommendations exist for catheter implantation in USPD, the impact of the technique itself on outcomes was found to be less significant compared with the post-implantation factors. USPD represents a safe and effective treatment modality for AKI, although complications such as catheter malfunctions, leakage, and peritonitis were observed. Furthermore, USPD demonstrated efficacy in managing CKD, although it was associated with a higher incidence of complications compared to conventional-start peritoneal dialysis. Despite its cost-effectiveness, PD requires greater technical expertise from medical professionals. Close supervision and pre-planning for catheter insertion are essential for CKD patients. Whenever feasible, an urgent start should be avoided. Nevertheless, in emergency scenarios, USPD does remain a safe and efficient approach.

Higher Serum Total Cholesterol to High-Density Lipoprotein Cholesterol Ratio Is Associated with Increased Mortality among Incident Peritoneal Dialysis Patients

This study evaluated the association of the serum total cholesterol to high-density lipoprotein cholesterol ratio (TC/HDL-C) with mortality in incident peritoneal dialysis (PD) patients. We performed a multi-center, prospective cohort study of 630 incident PD patients from 2008 to 2015 in Korea. Participants were stratified into quintiles according to baseline TC, HDL-C, LDL-C and TC/HDL-C. The association between mortality and each lipid profile was evaluated using multivariate Cox regression analysis. During a median follow-up period of 70.3 ± 25.2 months, 185 deaths were recorded. The highest TC/HDL-C group had the highest body mass index, percentage of diabetes and serum albumin level. Multivariate analysis demonstrated that the highest quintile of TC/HDL-C was associated with increased risk of all-cause mortality (hazard ratio 1.69, 95% confidence interval 1.04-2.76; p = 0.036), whereas TC, HDL-C and LDL-C were not associated with mortality. Linear regression analysis showed a positive correlation between TC/HDL-C and body mass index. Increased serum TC/HDL-C was an independent risk factor for mortality in the subgroup of old age, female, cardiovascular disease and low HDL-C. The single lipid marker of TC or HDL-C was not able to predict mortality in PD patients. However, increased serum TC/HDL-C was independently associated with all-cause mortality in PD patients.

Risk factors for mortality in patients undergoing peritoneal dialysis: a systematic review and meta-analysis

Aim

Inconsistent investigations of the risk factors for all-cause mortality in patients undergoing peritoneal dialysis (PD) were reported. The present meta-analysis aimed to assess the impact of some clinical characteristics on the risk of mortality in PD patients.

Methods

PubMed and Embase were systematically searched for studies evaluating the risk factors for all-cause mortality in PD patients. Hazard ratio (HR) and 95% confidence interval (CI) were derived using a random-effect or fixed-effect model considering the heterogeneity across studies.

Result

A total of 26 studies were included in this meta-analysis in accordance with the inclusion and exclusion criteria. Age, primary cardiovascular diseases, diabetes mellitus, and high level of alkaline phosphatase showed significant positive associations with elevated risk of all-cause and cardiovascular mortality in PD patients, while hemoglobin acted as a benefit factor. Furthermore, early onset of peritonitis, high peritoneal transport status, elevated body mass index and high-sensitivity C-reactive protein could also considerably increase the risk of all-cause mortality. The absolute serum level of magnesium, potassium, and uric acid required to improve survival in PD patients should be verified further.

Conclusions

Multiple factors could affect the risk of mortality in PD patients.

Association between body mass index and mortality in atrial fibrillation patients with and without diabetes mellitus: Insights from a multicenter registry study in China

BACKGROUND AND AIMS

The aim of this study was to evaluate the association between body mass index (BMI) and mortality in atrial fibrillation (AF) patients with and without diabetes mellitus (DM).

METHODS AND RESULTS

A total of 1991 AF patients were enrolled and divided into two groups according to whether they have DM at recruitment. Baseline information was collected and a mean follow-up of 1 year was carried out. The primary outcome was defined as all-cause mortality with the secondary outcomes including cardiovascular mortality, stroke and major adverse events (MAEs). Univariable and multivariable Cox regression were performed to estimate the association between BMI and 1-year outcomes in AF patients with and without DM. 309 patients with AF (15.5%) had comorbid DM at baseline. Patients with DM were more likely to have cardiovascular comorbidities, receive relevant medications but carry worse 1-year outcomes. Multivariable Cox regressions indicated that elevated BMI was related with reduced risk of all-cause mortality, cardiovascular mortality and major adverse events. Compared to normal weight, overweight [HR (95% CI): 0.548 (0.405-0.741), p < 0.001] and obesity [HR (95% CI): 0.541 (0.326-0.898), p = 0.018] were significantly related with decreased all-cause mortality for the entire cohort. Remarkably reduced all-cause mortality in the overweight [HR (95% CI): 0.497 (0.347-0.711), p < 0.001] and obesity groups [HR (95% CI): 0.405 (0.205-0.800), p = 0.009] could also be detected in AF patients without DM, but not in those with DM.

CONCLUSION

Elevated BMI was associated with reduced mortality in patients with AF. This association was modified by DM. The obesity paradox confined to AF patients without DM, but could not be generalized to those with DM.

Peritoneal dialysis patient selection from a comorbidity perspective

Despite many medical and socioeconomic advantages, peritoneal dialysis (PD) is an underutilized dialysis modality that in most countries is used by only 5%-20% of dialysis patients, while the vast majority are treated with in-center hemodialysis. Several factors may explain this paradox, such as lack of experience and infrastructure for training and monitoring of PD patients, organizational issues, overcapacity of hemodialysis facilities, and lack of economic incentives for dialysis centers to use PD instead of HD. In addition, medical conditions that are perceived (rightly or wrongly) as contraindications to PD represent barriers for the use of PD because of their purported potential negative impact on clinical outcomes in patients starting PD. While there are few absolute contraindications to PD, high age, comorbidities such as diabetes mellitus, obesity, polycystic kidney disease, heart failure, and previous history of abdominal surgery and renal allograft failure, may be seen (rightly or wrongly) as relative contraindications and thus barriers to initiation of PD. In this brief review, we discuss how the presence of these conditions may influence the strategy of selecting patients for PD, focusing on measures that can be taken to overcome potential problems.

Impact of body mass index on survival in patients undergoing peritoneal dialysis: Analysis of data from the Insan Memorial End-Stage Renal Disease Registry of Korea (1985-2014)

Background

Significant increases in the prevalence of obesity have been observed among patients with peritoneal dialysis (PD). The impact of body mass index (BMI) on survival remains unknown in Korean PD patients.

Methods

Among data of 80,674 patients on PD acquired from the Insan Memorial ESRD Registry database for the years 1985 to 2014, 6,071 cases were analyzed. Subjects were classified by baseline BMI; < 21.19 kg/m² (quartile 1, n = 1,518), 21.19 to 23.18 kg/m² (quartile 2, reference; n = 1,453), 23.19 to 25.71 kg/m² (quartile 3, n = 1,583), and > 25.71 kg/m² (quartile 4, n = 1,517).

Results

Mean age was 65.8 years, and baseline BMI was 23.57 kg/m². Numbers of male and diabetic patients were 3,492 (57.5%) and 2,192 (36.1%), respectively. Among 6,071 cases, 2,229 (36.7%) all-cause deaths occurred. As a whole, Kaplan–Meier survival curves according to BMI quartiles was significantly different (P = 0.001). All-cause mortality was significantly higher in quartile 4 than in the reference (hazard ratio [HR] = 1.154, 95% confidence interval [CI], 1.025–1.300; P = 0.018). There was no statistical difference in all-cause mortality among BMI quartiles in diabetic patients on PD. In non-diabetic patients, all-cause mortality of quartiles 1 and 3 was not different from the reference, but the HR was 1.176 times higher in quartile 4 (95% CI, 1.024–1.350; P = 0.022).

Conclusion

Baseline BMI > 25.71 kg/m² seems to be an important risk factor for all-cause mortality in Korean PD patients.

Effects of Excessive Body Fat Accumulation on Long-Term Outcomes During Peritoneal Dialysis

Background:Significant body fat accumulation is an inevitable but potentially serious problem in peritoneal dialysis (PD) patients. Whether excessive fat gain predicts long-term outcomes in these patients remains unknown.Methods:In this prospective cohort study (n = 297), the associations of excessive fat accumulation with patient survival and PD failure rate were examined. Based on dialysis duration at the time of study enrollment, patients were divided into short- (< 2 years) and long-term (> 2 years) groups. Body weight (BW) and body composition were measured twice, 12.8 ± 4.6 months apart. Excessive fat accumulation was defined as a 1-year change in the percentage of body fat (ΔPBF) over the highest quartile (5.0% for men, 5.4% for women).Results:Substantial 1-year increases in BW and PBF were observed only in the short-term group (p < 0.001 and p = 0.027, respectively); changes were insignificant in the long-term group. In the short-term group, the ΔPBF was associated closely with unfavorable baseline metabolic profiles, including old age, diabetes, obesity, elevated blood pressure, and edema. Accordingly, the mortality rate was significantly higher in patients with, than in those without, excessive fat accumulation (hazard ratio [HR] 3.26, 95% confidence interval [CI], 1.05 - 10.26). It also increased the incident risk of PD failure 2.22-fold (95% CI, 1.08 - 4.54), even after adjustment for diabetes, obesity, and fluid status. In the long-term group, fat gain had no impact on long-term prognosis.Conclusions:Excessive fat accumulation during the early period of PD was associated with baseline unhealthy metabolic profiles, a higher mortality rate, and a higher PD failure rate, independent of baseline obesity and fluid status.

Clinical value of body composition monitor to evaluate lean and fat tissue mass in peritoneal dialysis

BACKGROUND/OBJECTIVES

Bioimpedance analysis is often routinely performed in any dialysis unit to guide fluid management but can provide a reproduceable assessment of fat and muscle mass. We wished to determine the clinical significance of low muscle or high fat mass and the determinants that influence their change.

SUBJECTS/METHODS

We performed retrospective analysis of 824 patients on peritoneal dialysis who underwent routine repeated bioimpedance analysis measurements using the body composition monitor (BCM).

RESULTS

Lean tissue index (LTI) was an independent predictor of mortality when sex, age, PD vintage and diabetes status were included in the models (HR 0.93; 95% CI 0.86-1.00, p < 0.05) and when baseline serum albumin was included in a separate model (HR 0.86; 95% CI: 0.79-0.93, p < 0.001). High fat tissue index (FTI) was an independent predictor of mortality when demographic factors were included (HR 0.87; 95% CI: 0.78-0.97, p < 0.02), but not with the addition biochemical parameters. Changes in body composition of 206 patients over a 2-year follow-up period could not be predicted by baseline demographics, functional or biochemical assessments. However, there was a strong inverse relationship between changes in LTI and FTI. There were no associations between changes in body composition with prescribed dialysate glucose.

CONCLUSIONS

We showed body composition changes are common and complex. LTI was an independent predictor of survival. Changes in LTI and FTI could not be predicted by baseline parameters. BCM may be a sensitive and accurate tool to monitor changes in body composition during dialysis treatment.

The Relationship between Body Mass Index and Organism-Specific Peritonitis

Background

Obesity is increasingly prevalent worldwide, and a greater number of patients initiate renal replacement therapy with a high body mass index (BMI). This study aimed to evaluate the association between BMI and organism-specific peritonitis.

Methods

All adult patients who initiated peritoneal dialysis (PD) in Australia between January 2004 and December 2013 were included. Data were accessed through the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry. The co-primary outcomes of this study were time to first organism-specific peritonitis episode, specifically gram-positive, gram-negative, culture-negative, and fungal. Secondary outcomes were individual rates of organism-specific peritonitis for the same 4 microbiological categories.

Results

There were 7,381 peritonitis episodes among the 8,343 incident PD patients evaluated. After multivariable adjustment, obese patients (BMI 30 – 34.9 kg/m2) had an increased risk of fungal peritonitis (adjusted hazard ratio [HR] 1.69, 95% confidence interval [CI] 1.18 – 2.42), very obese patients (BMI ≥ 35 kg/m2) had a significantly higher risk of gram-positive peritonitis (HR 1.15, 95% CI 1.02 – 1.30), while both obese and very obese patients experienced significantly higher risks of gram-negative peritonitis (HR 1.29, 95% CI 1.11 – 1.50 and HR 1.30, 95% CI 1.08 – 1.57, respectively) compared with patients with normal BMI (20 – 24.9 kg/m2). Obesity and severe obesity were independently associated with increased incidence rate ratios of all forms of organism-specific peritonitis with a non-significant trend for severe obesity and gram-negative peritonitis association.

Conclusion

Among Australian patients, obesity and severe obesity are associated with significantly increased rates of gram-positive, gram-negative, fungal, and culture-negative peritonitis.

Advanced wasting in peritoneal dialysis patients

AIM

To identify patients with end-stage renal disease treated by peritoneal dialysis (PD) who had zero body fat (BF) as determined by analysis of body composition using anthropometric formulas estimating body water (V) and to compare nutritional parameters between these patients and PD patients whose BF was above zero.

METHODS

Body weight (W) consists of fat-free mass (FFM) and BF. Anthropometric formulas for calculating V allow the calculation of FFM as V/0.73, where 0.73 is the water fraction of FFM at normal hydration. Wasting from loss of BF has adverse survival outcomes in PD. Advanced wasting was defined as zero BF when V/0.73 is equal to or exceeds W. This study, which analyzed 439 PD patients at their first clearance study, used the Watson formulas estimating V to identify patients with V_Watson/0.73 ≥ W and compared their nutritional indices with those of PD patients with V_Watson/0.73 < W.

RESULTS

The study identified at the first clearance study two male patients with V_Watson/0.73 ≥ W among 439 patients on PD. Compared to 260 other male patients on PD, the two subjects with advanced wasting had exceptionally low body mass index and serum albumin concentration. The first of the two subjects also had very low values for serum creatinine concentration and total (in urine and spent peritoneal dialysate) creatinine excretion rate while the second subject had an elevated serum creatinine concentration and high creatinine excretion rate due, most probably, to non-compliance with the PD prescription.

CONCLUSION

Advanced wasting (zero BF) in PD patients, identified by the anthropometric formulas that estimate V, while rare, is associated with indices of poor somatic and visceral nutrition.

The association between body mass index and mortality among Asian peritoneal dialysis patients: A meta-analysis

BACKGROUND

Previous studies have revealed that increased body mass index (BMI) is associated with decreased mortality among hemodialysis patients. However, few studies have dealt with the association between BMI and mortality among patients undergoing peritoneal dialysis (PD) and even fewer studies have focused on the Asian PD patients. The reported studies were often non-conclusive and some even yielded contradictory results. This paper, to our best knowledge, registers the first attempt to systematically review the current literature and summarize new results on the association between BMI and mortality among the Asian PD population.

METHOD

A systematic literature review was performed in Medline and EMBASE to identify relevant cohort studies on all-cause and cardiovascular disease (CVD) mortality stratified by BMI categories tailored to Asians among the Asian PD population. We meta-analyzed individual results based on a random effect model, strictly complying with Preferred Reporting Items for Systematic Reviews and Meta-analysis.

RESULTS

The paper reviews seven cohort studies with a total of 3,610 Asian PD patients. Obese group (BMI = 25-29.9 kg/m2) was associated with higher risk of all-cause mortality (HR = 1.46, 95%CI [1.07-1.98]; p = 0.02) and CVD mortality (HR = 2.01, 95%CI [1.14-3.54]; p = 0.02), compared to the normal group (BMI = 18.5-22.9 kg/m2). The underweight group (BMI<18.5kg/m2) was also associated with an elevated risk of all-cause mortality (HR = 2.11, 95%CI [1.46-3.07]; p<0.001). No significant associations between BMI with all-cause mortality were found among the overweight group (23-24.9 kg/m2) (HR = 1.00, 95%CI [0.76-1.32]; p = 0.9). The association between BMI and CVD mortality risk among the underweight and overweight groups was found nonsignificant (p = 0.5 and 0.6 respectively).

CONCLUSION

Obesity is associated with increased mortality in Asian PD patients. The study indicates a "V-shaped" trend in the association between BMI and mortality in these patients.

Sarcopenic Obesity Definitions by Body Composition and Mortality in the Hemodialysis Patients

OBJECTIVE

Sarcopenic obesity (SO), a combination of low muscle mass and high fat mass, is considered as risk factor for mortality in general population. It is unclear if SO affects mortality in maintenance hemodialysis (MHD) patients. In this study, we aimed to determine whether body composition as assessed by currently available SO definitions is related to all-cause mortality in MHD subjects. We also examined the impact of applying different definitions on the prevalence of SO in our MHD database.

DESIGN

Retrospective analysis.

SUBJECTS

Adult patients on MHD for at least 3 months with no acute illness studied in the clinical research center between 2003 and 2011.

INTERVENTION

Assessment of body composition was performed using dual energy x-ray absorptiometry. SO (appendicular skeletal mass: arm lean mass + leg lean mass and fat mass) was defined according to Baumgartner definition, Janssen criteria 1, and Janssen criteria 2.

MAIN OUTCOME MEASURE

All-cause mortality and prevalence of SO. Patient deaths were ascertained from medical records and United States social security death index.

RESULTS

Of 122 participants, 62% were male; mean age was 46 years (interquartile range: 40, 54) in men and 50 years (44, 61) in women. Prevalence of SO ranged from 12% to 62% in men and 2% to 74% in female according to different definitions. SO prevalence was lowest using the Baumgartner criteria (all: 8%, men 12%, women: 2%) and highest according to the Janssen criteria 2 (all: 57%, men 46%, women 74%). There were 45 deaths during a median follow-up period of 44 (20, 76) months. SO by any definition was not statistically significantly associated with mortality during follow-up.

CONCLUSIONS

The current SO definitions are not applicable to predict increased risk of death in MHD patients. We found high degree of variation in the rates of SO when using different definitions. Future studies should focus on establishing MHD population-specific thresholds of muscle mass and adiposity for accurate prognostication.

Obese and diabetic patients with end-stage renal disease: Peritoneal dialysis or hemodialysis?

Obesity is a chronic disease that is increasingly prevalent around the world and is a well-recognized risk factor for type 2 diabetes and hypertension, leading causes of end-stage renal disease (ESRD). The obese diabetic patient with ESRD is a challenge for the nephrologist with regard to the type of renal replacement therapy that should be suggested and offered to the patient. There is no evidence that either peritoneal dialysis or hemodialysis is contraindicated in obese ESRD patients. In the literature, we can find a discrepancy in the impact of obesity on mortality among hemodialysis vs. peritoneal dialysis patients. Several studies in hemodialysis patients suggest that a higher BMI confers a survival advantage - the so-called "reverse epidemiology". In contrast, the literature among obese peritoneal dialysis patients is inconsistent, with various studies reporting an increased risk of death, no difference, or a decreased risk of death. Many of these studies only spanned across a few years, and this is probably too short of a time frame for a realistic assessment of obesity's impact on mortality in ESRD patients. The decision for dialysis modality in an obese diabetic patient with ESRD should be individualized. According to the results of published studies, we cannot suggest PD or HD as a better solution for all obese diabetic patients. The obese patient should be educated about all their dialysis options, including home dialysis therapies. In this review, the available literature related to the dialysis modality in obese patients with diabetes and ESRD was reviewed.

Shortage of Appendicular Skeletal Muscle Is an Independent Risk Factor for Mortality in Peritoneal Dialysis Patients

♦ BACKGROUND: Limited data are available on clinical outcomes among peritoneal dialysis patients with shortage of appendicular skeletal muscle (ASM). In this study, we tested the hypothesis that the shortage of ASM is an independent risk factor for mortality in continuous ambulatory peritoneal dialysis (CAPD) patients. ♦ METHODS: Adult patients undergoing CAPD between March and August 2007 in a single center in China were recruited in this prospective cohort study. Body composition, protein/energy intake, clinical, and biochemical data were collected at baseline, 6 months, and 12 months. End points were all-cause mortality by 12 September 2014. The mean follow-up time was 60.21 (± 24.45) months (11.00 - 89.00). ♦ RESULTS: Compared with the baseline, the mean value of ASM in CAPD patients decreased at 12 months (19.40 ± 5.60 vs 21.85 ± 6.14, p < 0.001). According to the estimation of patient survival by Kaplan-Meier, patients with a shortage of ASM had a worse survival rate than those with normal ASM (χ² = 16.588, p < 0.001). In the Cox's proportional hazards model, patients' survival was independently associated with a shortage of ASM (hazard ratio [HR] = 2.318, p = 0.024, 95% confidence interval [CI] = 1.116 - 4.812). Standard daily protein intake (stDPI) and standard daily energy intake (stDEI) in patients with a shortage of ASM were significantly lower than those in patients with normal ASM in the first follow-up year (t = 2.067, p = 0.041; t = 3.673, p = 0.001). ♦ CONCLUSIONS: A shortage of ASM is an independent risk factor for mortality in CAPD patients. Further studies are needed to demonstrate that nutritional intervention helps with improving muscle mass and, consequently, the survival of CAPD patients.

Metabolic syndrome and obesity in peritoneal dialysis

Metabolic syndrome (MS) refers to clustering of features related to increased risk of cardiovascular disease, which include obesity or central obesity, dyslipidemia, diabetes mellitus or insulin resistance, together with hypertension. The prevalence of MS in end-stage renal failure patients on peritoneal dialysis is quite common, ranging from 40% to 60%, depending on the population studied and the definition used. However, there are controversies about the clinical outcome of patients with MS, particularly in the area of obesity. Whether peritoneal dialysis predisposes patients to MS is another unsolved issue. Despite these controversies, preventing patients from developing MS is important, at least from a theoretical point of view.

Association of Body Mass Index and Body Mass Index Change with Mortality in Incident Peritoneal Dialysis Patients

Although high body mass index (BMI) appears to confer a survival advantage in hemodialysis patients, the association of BMI with mortality in continuous ambulatory peritoneal dialysis (CAPD) patients is uncertain. We enrolled incident CAPD patients and BMI was categorized according to World Health Organization classification for Asian population. BMI at baseline and one year after the initiation of peritoneal dialysis (PD) treatment was assessed to calculate the BMI change (∆BMI). Patients were split into four categories according quartiles of ∆BMI. Kaplan-Meier method and Cox regression proportional hazard analysis were performed to assess the association of BMI on outcomes. A total of 1263 CAPD patients were included, with a mean age of 47.8 ± 15.0 years, a mean BMI of 21.58 ± 3.13 kg/m². During a median follow-up of 25.3 months, obesity was associated with increased risk for cardiovascular diseases (CVD) death (adjusted hazard ratio (AHR) 2.01; 95% CI 1.14, 3.54), but not all-cause mortality. Additionally, patients with more BMI decline (>0.80%) during the first year after CAPD initiation had an elevated risk for both all-cause (AHR: 2.21, 95% CI 1.23-3.95) and CVD mortality (AHR 2.31, 95% CI 1.11, 4.84), which was independent of baseline BMI values.

Peritoneal Dialysis in Asia

BACKGROUND

There is a growing demand of dialysis in Asia for end-stage renal failure patients. Diabetes mellitus is the leading cause of end-stage renal failure in many countries in Asia.

SUMMARY

The growth of peritoneal dialysis (PD) in Asia is significant and seeing a good trend. With the enhanced practices of PD, the quality of care in PD in Asia is also improved. Overall, PD and hemodialysis (HD) are comparable in clinical outcome. There is a global trend in the reduction of peritonitis rates and Asian countries also witness such improvement. The socio-economic benefits of PD for end-stage renal failure patients in both urban and rural areas in the developed and developing regions of Asia are an important consideration. This can help to reduce the financial burden of renal failure in addressing the growing demand of patients on dialysis. Initiatives should be considered to further drive down the cost of PD in Asia.

KEY MESSAGES

Growing demand for dialysis by an increasing number of end-stage renal failure patients requires the use of a cost-effective quality dialysis modality. PD is found to be comparable to HD in outcome and quality. In most countries in Asia, PD should be more cost-effective than HD. A 'PD-first' or a 'PD as first considered therapy' policy can be an overall strategy in many countries in Asia in managing renal failure patients, taking the examples of Hong Kong and Thailand.

FACTS FROM EAST AND WEST

(1) PD is cheaper than HD and provides a better quality of life worldwide, but its prevalence is significantly lower than that of HD in all countries, with the exception of Hong Kong. Allowing reimbursement of PD but not HD has permitted to increase the use of PD over HD in many Asian countries like Hong Kong, Vietnam, Taiwan, Thailand, as well as in New Zealand and Australia over the last years. In the Western world, however, HD is still promoted, and the proportion of patients treated with PD decreases. Japan remains an exception in Asia where PD penetration is very low. Lack of adequate education of practitioners and information of patients might as well be reasons for the low penetration of PD in both the East and West. (2) Patient survival of PD varies between and within countries but is globally similar to HD. (3) Peritonitis remains the main cause of morbidity in PD patients. South Asian countries face specific issues such as high tuberculosis and mycobacterial infections, which are rare in developed Asian and Western countries. The infection rate is affected by climatic and socio-economic factors and is higher in hot, humid and rural areas. (4) Nevertheless, the promotion of a PD-first policy might be beneficial particularly for remote populations in emerging countries where the end-stage renal disease rate is increasing dramatically.