The Impact of Timing of Dialysis Initiation on Mortality in Patients with Peritoneal Dialysis

Evaluation of complications in urgent start peritoneal dialysis: Single-center experience

BACKGROUND

Patients who were urgent start peritoneal dialysis (USPD) were evaluated in terms of complications.

METHODS

The data from 102 patients (43 males and 59 females, mean age 58.18 ± 15.3 years) who were on peritoneal dialysis with a placed catheter between January 2014 and June 2019 in our Nephrology clinic was evaluated. The patients were divided into three groups according to the starting time of peritoneal dialysis. The development of complications between the groups (peritonitis, leakage, hernia), hemodialysis return time and overall survival times were compared.

RESULTS

There was no difference between the groups in terms of survival and complications. Diabetes, advanced age, albumin values were found to be risk factors for mortality, while no differences were found between the groups in terms of complications and mortality.

CONCLUSION

USPD can be recommended for both because it provides a permanent dialysis option and because it leads to fewer complications than urgent start HD.

Risk factors for early death in urgent-start peritoneal dialysis patients: A multicenter retrospective cohort study

BACKGROUND

Assess risk factors for early death in patients who underwent urgent-start peritoneal dialysis (USPD).

METHODS

Patients who initiated USPD in five peritoneal dialysis centers from 2013 to 2019 were screened in this multicenter retrospective cohort study. Risk factors for all-cause mortality within 3 months were explored.

RESULTS

A total of 1265 USPD patients with 43 early deaths were included. Cox regression analyses showed that age older than 60 years (hazard ratio [HR], 3.054; 95% CI [1.597, 5.842]; p = 0.001), albumin less than 30 g/L (HR, 2.234; 95%CI [1.207, 4.136]; p = 0.011), blood glucose greater than 7 mmol/L (HR, 2.766; 95%CI [1.477, 5.180]; p = 0.001), higher estimated glomerular filtration rate (eGFR; HR, 1.121; 95%CI [1.071, 1.172]; p = 0.000), and poor stages of heart failure (class IV compared with class 0-I; HR, 5.165; 95%CI [2.544, 10.486]; p = 0.000) were independent predicting factors for early death.

CONCLUSIONS

Risk factors for early death were older age, hypoproteinemia, hyperglycemia, higher eGFR, and severe heart failure.

Incremental peritoneal dialysis in incident end-stage kidney disease patients

BACKGROUND

This retrospective cohort study investigated the characteristics and outcomes of the end-stage kidney disease (ESKD) patients treated with incremental peritoneal dialysis (PD) at a large academic centre.

METHODS

ESKD patients initiating PD with a dialysate volume ≤6 L/day were analysed.

RESULTS

One hundred and seventy-five patients were included and were followed up for 352.6 patient-years. The baseline residual kidney function (RKF) was 8.3 ± 3.4 mL/min/1.73 m². The unadjusted 1- to 5-year patient survival rate was 89.6%, 80.4%, 65.4%, 62.7% and 48.8%, respectively, and the corresponding time on PD therapy rate was 95.1%, 89.1%, 89.1%, 82.4% and 77.6%. Greater initial PD dose (hazard ratio = 1.608, 95% confidence interval 1.089-2.375) was associated with death after adjusting for age, Charlson comorbidity index (CCI), haemodialysis prior to PD, assisted PD and baseline RKF, likely as a result of residual confounding. There was no association with PD discontinuation. The average peritonitis rate and hospitalisation rate were 0.122 and 0.645 episodes per patient-year, respectively. The dialysate volume increased from 4.5 (4.3-5.7) L/day to 8.0 (6.0-9.8) L/day at 5 years. Fifty-seven (32.6%) patients graduated to full-dose PD at a median time of 10.3 (6.2, 15.7) months. Male sex, greater body mass index and lower baseline serum albumin were risk factors for increasing PD dose to over 6 L/day within 1 year.

CONCLUSIONS

Incremental PD is a safe approach to initiate dialysis, and it offers satisfactory outcomes. Close monitoring, comprehensive evaluation of clinical responses and prompt adjustment of the prescription as needed play a crucial role in this patient-centred treatment.

Peritoneal Dialysis Guidelines 2019 Part 1 (Position paper of the Japanese Society for Dialysis Therapy)

Approximately 10 years have passed since the Peritoneal Dialysis Guidelines were formulated in 2009. Much evidence has been reported during the succeeding years, which were not taken into consideration in the previous guidelines, e.g., the next peritoneal dialysis PD trial of encapsulating peritoneal sclerosis (EPS) in Japan, the significance of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), the effects of icodextrin solution, new developments in peritoneal pathology, and a new international recommendation on a proposal for exit-site management. It is essential to incorporate these new developments into the new clinical practice guidelines. Meanwhile, the process of creating such guidelines has changed dramatically worldwide and differs from the process of creating what were “clinical practice guides.” For this revision, we not only conducted systematic reviews using global standard methods but also decided to adopt a two-part structure to create a reference tool, which could be used widely by the society’s members attending a variety of patients. Through a working group consensus, it was decided that Part 1 would present conventional descriptions and Part 2 would pose clinical questions (CQs) in a systematic review format. Thus, Part 1 vastly covers PD that would satisfy the requirements of the members of the Japanese Society for Dialysis Therapy (JSDT). This article is the duplicated publication from the Japanese version of the guidelines and has been reproduced with permission from the JSDT.

Early initiation of PD therapy in elderly patients is associated with increased risk of death

Background

The effect of early initiation of dialysis on outcomes of patients with end-stage renal disease (ESRD) remains controversial. We conducted this study to investigate the association between the timing of peritoneal dialysis (PD) initiation and mortality in different age groups.

Methods

In this single-centre cohort study, incident patients receiving PD from 1 January 2006 to 31 December 2016 were enrolled. Patients were categorized into three groups according to the estimated glomerular filtration rate (eGFR) at the initiation of PD, with early, mid and late initiation of PD defined as eGFR ≥7.5, 5–7.5 and <5 mL/min/1.73 m², respectively.

Results

A total of 2133 incident patients receiving PD were enrolled with a mean age of 47.1 years, 59.6% male and 25.3% with diabetes, of whom 1803 were young (age <65 years) and 330 were elderly (age ≥65 years). After multivariable adjustment, the overall and cardiovascular (CV) mortality risks for young patients receiving PD were not significantly different between these three groups. However, for elderly patients, early initiation of PD therapy was associated with increased risks of all-cause {hazard ratio [HR} 1.54 [95% confidence interval (CI) 1.06–2.25]} and CV [HR 2.07 (95% CI 1.24–3.48)] mortality compared with late initiation of PD, while no significant difference was observed in overall or CV mortality between the mid- and late-start groups.

Conclusions

No significant difference in mortality risk was found among the three levels of eGFR at PD therapy initiation in young patients, while early initiation of PD was associated with a higher risk of overall and CV mortality among elderly patients.

Association between timing of peritoneal dialysis initiation and mortality in end-stage renal disease

Despite the widespread use of chronic dialysis for end-stage renal disease (ESRD), there is no consensus on the optimal timing of initiating renal replacement therapy. Over the past decade, a worldwide trend toward increasing glomerular filtration rate at the initiation of dialysis has been noted. However, available data indicate that early dialysis has no survival benefit or is harmful. Peritoneal dialysis (PD) is one alternative for ESRD and has potential survival factors different from those of hemodialysis. The association between the timing of PD initiation and survival is unclear. This review examines the effect of the timing of dialysis on clinical outcomes in PD patients.

Survival predictors in anuric patients on peritoneal dialysis: A prospective, multicenter, propensity score-matched cohort study

Prevalent anuric peritoneal dialysis (PD) patients usually have higher mortality than PD patients with residual urine volume. We aimed to evaluate the predictors of survival in anuric PD patients. Anuric PD patients (n = 505, <100 mL of daily urine) enrolled in Korean nationwide prospective cohort were analyzed. Survived and non-survived anuric PD patients were compared by propensity score matching analysis with a ratio of two to one. The propensity method was used to adjust for patient age, dialysis duration, and presence of diabetes. Among the total anuric PD patients, non-survived patients showed a significantly older age, higher incidence of diabetes, coronary artery disease, and arrhythmia, and lower serum creatinine and albumin. After propensity score matching, multivariate Cox regression analysis for patient survival showed a decreasing risk as serum albumin increased (HR = 0.347, p = 0.0094). Analysis using the receiver-operating-characteristic (ROC) curve showed that survival could be predicted with a sensitivity of 59.4% and a specificity of 63.2% using a cutoff value of 3.6 g/dL of serum albumin in unmatched total PD patients. The beneficial impact of high albumin level on death was significantly greater for patients with older age (≥50 years), no diabetes, low ultrafiltration (UF) volume (<1000 mL/day), and low levels of serum creatinine (<10 mg/dL), total cholesterol (<177.5 mg/dL), ferritin (<100 ng/mL), and high-sensitivity C-reactive protein (hs-CRP) (<0.1 mg/dL). Survival in anuric PD patients was associated with age, comorbidities, and nutritional factors such as creatinine and albumin. After adjustment by propensity score matching, serum albumin level was an independent predictor for survival in anuric PD patients.

Effect of the timing of dialysis initiation on left ventricular hypertrophy and ınflammation in pediatric patients

BACKGROUND

The optimal time for dialysis initiation in adults and children with chronic kidney disease remains unclear. The aim of this study was to evaluate the impact of dialysis timing on different outcome parameters, in particular left ventricular (LV) morphology and inflammation, in pediatric patients receiving peritoneal dialysis and hemodialysis.

METHODS

The medical records of pediatric dialysis patients who were followed-up in nine pediatric nephrology centers in Turkey between 2008 and 2013 were retrospectively reviewed. In addition to demographic data, we retrieved anthropometric measurements, data on dialysis treatment modalities, routine biochemical parameters, complete blood count, serum ferritin, parathormone, C-reactive protein (CRP), and albumin levels, as well as echocardiographic data and hospitalization records. The patients were divided into two groups based on their estimated glomerular filtration rate (eGFR) levels at dialysis initiation, namely, an early-start group, characterized by an eGFR of >10 ml/min/1.73 m², and a late-start group, with an eGFR of < 7 ml/min/1.73 m². The collected data were compared between these groups.

RESULTS

A total of 245 pediatric dialysis patients (mean age ± standard deviation 12.3 ± 5.1 years, range 0.5-21 years) were enrolled in this study. Echocardiographic data were available for 137 patients, and the mean LV mass index (LVMI) was 58 ± 31 (range 21-215) g/m^2.7. The LVMI was 75 ± 30 g/m^2.7(n = 81) and 34 ± 6 g/m^2.7(n = 56) in patients with or without LV hypertrophy (LVH) (p < 0.001). Early-start (eGFR >10 ml/min/1.73 m²) versus late-start dialysis (eGFR < 7 ml/min/1.73 m²) groups did not significantly differ in LVMI and LVH status (p > 0.05) nor in number of hospitalizations. Serum albumin levels were significantly higher in the early-dialysis group compared with the late-dialysis group (3.3 ± 0.7 vs. 3.1 ± 0.7 g/dl, respectively; p < 0.05). The early-start group had relatively higher time-averaged albumin levels (3.2 ± 0.5 vs. 3.1 ± 0.5 g/dl; p = > 0.05) and relatively lower CRP levels (3.64 ± 2.00 vs. 4.37 ± 3.28 mg/L, p > 0.05) than the late-start group, but these differences did not reach statistical significance.

CONCLUSION

Although early dialysis initiation did not have a significant effect on important clinical outcome parameters, including LVH, inflammatory state, and hospitalization, in our pediatric dialysis patients, this area of study deserves further attention.

Timing of Dialysis Initiation: What Has Changed Since IDEAL?

The optimal timing of initiation of maintenance dialysis in patients with end-stage renal disease currently is unknown. This transition period is one of exceptionally high vulnerability for patients; annual mortality rates in stage 5 chronic kidney disease through the first year of maintenance dialysis exceed 20%. The results of the Initiating Dialysis Early and Late (IDEAL) study, a randomized trial that tested the impact of dialysis initiation at two different levels of kidney function on outcomes, showed no significant difference in survival or other patient-centered outcomes between treatment groups. These data have challenged the established paradigm of using estimates of glomerular filtration as the primary guide for initiation of maintenance dialysis and illustrate the compelling need for research to optimize the high-risk transition period from chronic kidney disease to end-stage renal disease. This article reviews the findings of the IDEAL study and summarizes the evolution of research findings, updated clinical practice guidelines, and trends in dialysis initiation practices in the United States in the 6 years since the publication of the results from IDEAL. Complementary strategies to the use of estimated glomerular filtration rate to optimally time the initiation of maintenance dialysis and potentially improve patient-centered outcomes also are considered.

The Glomerular Filtration Rate (GFR) at Dialysis Initiation and Mortality in Chronic Kidney Disease (CKD) in East Asian Populations: A Meta-analysis

Objective The impact of dialysis initiation on survival is still somewhat controversial. Given that race or ethnicity has been observed to be a predictor of mortality and the rate of progression of chronic kidney disease, we conducted a meta-analysis to investigate the effect of early vs. late dialysis initiation on mortality in East Asian populations. Methods All eligible cohort studies of target were selected from the MEDLINE (PubMed), EMBASE, The Cochrane Library and the Clinical Trials Registry databases from inception to October 2014. The data were extracted with all-cause mortality rates as the primary outcome, and pooled adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated. Results Ten studies examined the association between early vs. late dialysis initiation and mortality. Compared to late dialysis initiation, patients who received early dialysis initiation had a higher overall mortality risk (adjusted HR, 1.36; 95% CI, 1.0-1.85; p<0.05) in East Asian populations. In a subgroup analysis, baseline characteristic differences (adjusted HR, 2.0; 95%CI, 1.56-2.57; p<0.001), initial dialysis modalities (adjusted HR, 2.12; 95% CI, 1.72-2.62; p<0.001) and follow up duration (adjusted HR, 1.59; 95% CI, 1.19-2.12; p=0.002), demonstrated that the association between early dialysis initiation and mortality were significant. Conclusion A higher glomerular filtration rate (early) at the initiation of dialysis is associated with a higher all-cause mortality risk in East Asian populations.

Patient characteristics and risk factors of early and late death in incident peritoneal dialysis patients

This study was conducted to identify key patient characteristics and risk factors for peritoneal dialysis (PD) mortality in terms of different time-point of death occurrence. The incident PD patients from January 1, 2006 to December 31, 2013 in our PD center were recruited and followed up until December 31, 2015. Patients who died in the early period (the first 3 months) were older, had higher neutrophil to lymphocyte ratio (N/L), serum phosphorus, and uric acid level, and had lower diastolic pressure, hemoglobin, serum albumin, and calcium levels. After adjustment of gender, age, and PD inception, higher N/L level [hazard ratio (HR) 1.115, P = 0.006], higher phosphorus lever (HR 1.391, P < 0.001), lower hemoglobin level (HR 0.596, P < 0.001), and lower serum albumin level (HR 0.382, P = 0.017) were risk factors for early mortality. While, presence of diabetes (HR 1.627, P = 0.001), presence of cardiovascular disease (HR 1.847, P < 0.001) and lower serum albumin level (HR 0.720, P = 0.023) were risk factors for late mortality (over 24 months). In conclusion, patient characteristics and risk factors associated with early and late mortality in incident PD patients were different, which indicated specific management according to patient characteristics at the initiation of PD should be established to improve PD patient survival.