[Transfer from chronic haemodialysis to peritoneal dialysis]

Dialysis modality utilization patterns and mortality in older persons initiating dialysis in Australia and New Zealand

AIM

The benefits of dialysis in the older population remain highly debated, particularly for certain dialysis modalities. This study aimed to explore the dialysis modality utilization patterns between in-centre haemodialysis (ICHD), peritoneal dialysis (PD) and home haemodialysis (HHD) and their association with outcomes in older persons.

METHODS

Older persons (≥75 years) initiating dialysis in Australia and New Zealand from 1999 to 2018 reported to the Australia and New Zealand Dialysis and Transplant (ANZDATA) registry were included. The main aim of the study was to characterize dialysis modality utilization patterns and describe individual characteristics of each pattern. Relationships between identified patterns and survival, causes of death and withdrawal were examined as secondary analyses, where the pattern was considered as the exposure.

RESULTS

A total of 10 306 older persons initiated dialysis over the study period. Of these, 6776 (66%) and 1535 (15%) were exclusively treated by ICHD and PD, respectively, while 136 (1%) ever received HHD during their dialysis treatment course. The remainder received both ICHD and PD: 906 (9%) started dialysis on ICHD and 953 (9%) on PD. Different individual characteristics were seen across dialysis modality utilization patterns. Median survival time was 3.0 (95%CI 2.9-3.1) years. Differences in survival were seen across groups and varied depending on the time period following dialysis initiation. Dialysis withdrawal was an important cause of death and varied according to individual characteristics and utilization patterns.

CONCLUSION

This study showed that dialysis modality utilization patterns in older persons are associated with mortality, independent of individual characteristics.

Outcomes after transfer from hemodialysis to peritoneal dialysis vs peritoneal dialysis as initial therapy: A systematic review and meta-analysis

Outcomes of patients who are transferred to peritoneal dialysis (PD) after an initial phase of hemodialysis (HD) compared to patients initiating dialysis with PD is controversial. We performed a systematic literature to assess evidence. Primary outcome was overall survival (OS), while secondary outcomes were technique failure, mortality and peritonitis. Meta-analysis indicated that PD initial group had significantly better OS as compared to HD to PD group. Pooled analysis demonstrated a significantly higher probability of technique failure in the HD to PD group as compared to PD initial group. Mortality rate in HD to PD group was significantly higher but there was no statistically significant difference in peritonitis rates between the two groups. On meta-regression analysis, transfer from HD to PD due to vascular access problems was associated with significantly reduced probability of OS. Our study indicates that patients transferred from HD to PD after at least 3 months of HD therapy may have reduced OS as compared to patients initiating dialysis with PD. Our findings lend some support to PD first policy and the need for heightened vigilance among the switched patients to monitor for adverse events.

Dialysis access: issues related to conversion from peritoneal dialysis to hemodialysis and vice versa

Hemodialysis (HD) and peritoneal dialysis (PD) represent two complementary modalities of renal replacement therapy (RRT) for end-stage renal disease patients. Conversion between the two modalities is frequent and more likely to happen from PD to HD. Every year, 10% of PD patients convert to HD, suggesting the need for recommendations on how to proceed with the creation of a vascular access in these patients. Criteria for selecting patients who would likely fail PD, and therefore take advantage of a backup access, are undefined. Creating backup fistulas at the time of PD treatment start to allow emergency access for HD has proved to be inefficient, but it may be considered in patients with progressive difficulty in achieving adequate depuration and/or peritoneal ultrafiltration. A big challenge is represented by patients switching from PD to HD for unexpected infectious complications. Those patients need to start HD with a central venous catheter (CVC), but an alternative approach might be using an early cannulation graft, provided that infection has been cleared by the circulation. An early cannulation graft might also be used to considerably shorten the time spent using a CVC. In patients who need a conversion from HD to PD, urgent-start PD is now an accepted and well-established approach.

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

PURPOSE

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

METHODS

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

MAIN RESULTS

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

CONCLUSION

The survival is similar between hemodialysis and peritoneal dialysis.

The impact of transfer from hemodialysis on peritoneal dialysis technique survival

BACKGROUND

A significant proportion of peritoneal dialysis (PD) patients receive an initial period of hemodialysis (HD) before transitioning to PD ("PD-switch"). We sought to better understand the risks of PD technique failure (TF) and mortality for those patients compared with patients starting with PD as their first dialysis modality ("PD-first").

METHODS

Using Canadian Organ Replacement Register data, we compared the risk of PD TF between PD-first and PD-switch patients within the first year after HD initiation. In a secondary analysis, the PD-switch patients were stratified into three groups based on timing of the switch from initial HD to PD as follows: 0 - 90 days, 91 - 180 days, and 181 - 365 days. Each group was compared with PD-first patients for risk of PD TF and death.

RESULTS

Between 2001 and 2010, 9404 patients initiated PD as their first renal replacement therapy, and 3757 switched from HD to PD. After multivariable adjustment, the risk of PD TF was higher among PD-switch patients than among PD-first patients [adjusted hazard ratio (AHR): 1.37; 95% confidence interval (CI): 1.26 to 1.49], particularly within the first year after the switch from HD to PD (AHR: 1.51; 95% CI: 1.36 to 1.68). There was no association between time on HD within the first year and subsequent risk of PD TF. For all the stratified PD-switch groups, death rates were higher than those for PD-first patients.

CONCLUSIONS

Compared with patients who start renal replacement therapy with PD, those who transfer from HD to PD within the first year on dialysis experience higher rates of PD TF and death, with the highest risk being observed in the initial year after the switch to PD.

Clinical outcomes of peritoneal dialysis patients transferred from hemodialysis: a matched case-control study

OBJECTIVE

Our study aimed to evaluate clinical outcomes of patients transferred to peritoneal dialysis (PD) because of complications related to hemodialysis (HD). ♢

METHODS

In a 1:2 matched case-control study, we compared patient and technique survival between patients initially treated with HD for at least 3 months and then transferred to PD (transfer group) and patients started on and continuing with PD (no-transfer group). ♢

RESULTS

All baseline characteristics except for initial residual urinary output were comparable between the groups. Compared with patients in the transfer group, patients in the no-transfer group had a higher initial daily residual urinary output [850 mL (range: 600 - 1250 mL) vs 0 mL (range: 0 - 775 mL/d), p = 0.000]. The main reasons for transfer to PD were vascular access problems and cardiovascular disease. Patient survival and technique failure rates did not significantly differ between the groups (p > 0.05). The 1-, 3-, and 5-year patient survival rates were 80.0%, 53.7%, and 27.6% in the transfer group and 89.7%, 60.2%, and 43.1% in the no-transfer group. Age (per 10 years) and serum albumin were independent risk factors for long-term survival in PD patients. Relative risk of either death or technique failure was not significantly increased in patients transferred from HD. ♢

CONCLUSIONS

Patients who transferred to PD after failing HD had outcomes on PD similar to those for patients who started with and were maintained on PD. Age (per 10 years) and serum albumin were independent risk factors for long-term survival in PD patients.

Patient outcome in primary peritoneal dialysis patients versus those transferred from hemodialysis and transplantation

BACKGROUND

According to the concept of integrated care, renal transplantation, peritoneal dialysis (PD), and hemodialysis (HD) should be considered three complementary methods of renal replacement therapy. This study tried to evaluate patient outcomes in three different groups of PD patients, namely primary PD patients, those transferred to PD with failing kidney transplant, and those transferred to PD from HD.

METHOD

From January 1, 1995, to end of 2006 from 26 PD centers, 1,355 patients including demographic, clinical and laboratory data, which were monthly collected through questionnaires, were enrolled in the study. We compared patients' characteristics, factors affecting patient survival, and patient outcomes between primary PD patients (group 1, n = 1,067), patients transferred from transplantation (group 2, n = 43) and those transferred from HD (group 3, n = 245), which had been on HD for at least 3 months before switching to PD.

RESULTS

There was no difference in the proportion of patients with diabetes in the three groups. Overall, 238 patients (17.5%) were transferred to HD but there was no significant difference in PD technique survival on between the three groups. Death occurred in 256 (24%), 3 (7%) and 65 (26.5%) subjects in groups 1, 2 and 3, respectively. Most patients (81.5%) in group 2 underwent re-transplantation. The Kaplan-Meier survival rates were not different between the three groups. In the Cox multiple regression model, age, presence of diabetes and serum albumin level significantly influenced patient survival.

CONCLUSION

We concluded that PD could be considered safe for patients experiencing complications on HD, as well as for those with renal transplantation.

Therapy outcome in peritoneal dialysis patients transferred from haemodialysis

BACKGROUND

Haemodialysis (HD) and peritoneal dialysis (PD) should be regarded as complementary methods of renal replacement therapy. Approximately 10-20% of patients on PD are transferred annually to HD due to technique failure. Much smaller proportion of patients changes modality from HD to PD, predominantly due to vascular access problems, cardiac disease or patient preference. The effects of these transfers on therapy outcome, patient and technique survival have not been studied, with research focusing on outcome measures within the single modality and comparisons between the two methods.

METHODS

We have analysed retrospectively a cohort of 264 patients treated with PD in a single PD centre during 1994-2006. Patient characteristics, therapy measures and outcome of patients were compared between patients for whom PD was the initial method of renal replacement therapy (group 1, n = 197) and those transferred to PD from haemodialysis because of complications (group 2, n = 67). The Kaplan-Meier method and Cox proportional hazards multiple regression analysis were used to assess patient and technique survival.

RESULTS

In patients transferred from HD, significantly less had diabetes (11.9% versus 38.1%, P < 0.0001) and there were also significantly more females (57% versus 42.2%, P < 0.05). Baseline Kt/V was significantly higher in the primary PD therapy group (2.46 +/- 0.57 versus 2.11 +/- 0.48, P < 0.001), due to lower residual renal function in patients transferred from HD. Group 2 had also significantly higher peritonitis rate (0.86 versus 0.62 episode/year, P < 0.05). During the time of observation, 71 patients have died, in 100 patients kidney transplantation was performed, 56 were transferred to HD, renal function recovered in 5 and 32 were still on PD at the end of the study. No significant differences were observed in unadjusted patient survival, but technique survival was significantly lower in group 2 (P < 0.05). In the Cox multiple regression model, diabetes status, age and albumin level significantly influenced survival. Relative risk of death was not increased significantly in patients transferred from HD.

CONCLUSIONS

Our data suggest that outcome of patients transferred from HD is similar to that achieved in patients in whom PD is the first choice therapy. Thus, this option should be strongly considered in patients experiencing complications on HD, mainly vascular access problems, heart failure or intradialytic hypotension.

[News in peritoneal dialysis]

Peritoneal dialysis, like hemodialysis, is a first-line therapy for patients with end-stage renal disease. Progress in medical devices and materials has reduced infectious complications such as peritonitis and catheter exit-site infections and thus decreased morbidity. Peritoneal dialysis fluids are increasingly biocompatible, result in fewer glucose degradation products, protect the peritoneal membrane better and thus improve tolerance. The maintenance of residual renal function, together with better comfort and no pain, help control the fluid and sodium balance. Automated peritoneal dialysis can be performed each night, either autonomously or assisted by a visiting nurse twice a day (to prepare, connect, and disconnect the machine). This treatment can thus be provided to most patients, regardless of their age. Peritoneal dialysis is indicated principally for young people waiting for a kidney transplantation (to preserve their vascular network), elderly patients who wish to remain either at home or in an institution, and patients with cardiac insufficiency, because of the better hemodynamic tolerance. Numerous obstacles, mainly nonmedical, still impede the development of peritoneal dialysis. Patients seen in emergencies start hemodialysis without necessarily receiving any information about peritoneal dialysis. Indeed, neither physicians nor patients receive adequate information.