Current Challenges and Opportunities in PD

Mortality of Peritoneal Dialysis versus Hemodialysis in Older Adults: An Updated Systematic Review and Meta-Analysis

INTRODUCTION

The optimal choice of dialysis modality remains contentious in older adults threatened by advanced age and high risk of comorbidities.

METHODS

We conducted a systematic review and meta-analysis of cohort and case-control studies to assess mortality risk between peritoneal dialysis (PD) and hemodialysis (HD) in older adults using PubMed, Embase, and the Cochrane Library database from inception to June 1, 2022. The outcome of interest is all-cause mortality.

RESULTS

Thirty-one eligible studies with >774,000 older patients were included. Pooled analysis showed that PD had a higher mortality rate than HD in older dialysis population (HR 1.17, 95% CI: 1.10-1.25). When stratified by co-variables, our study showed an increased mortality risk of PD versus HD in older patients with diabetes mellitus or comorbidity who underwent longer dialysis duration (more than 3 years) or who started dialysis before 2010. However, definitive conclusions were constrained by significant heterogeneity.

CONCLUSION

From the survival point of view, caution is needed to employ PD for long-term use in older populations with diabetes mellitus or comorbid conditions. However, a tailored treatment choice needs to take account of what matters to older adults at an individual level, especially in the context of limited survival improvements and loss of quality of life. Further research is still awaited to conclude this topic.

Relationship between gut microbiota and nutritional status in patients on peritoneal dialysis

Malnutrition is a common complication in the dialysis population, both hemodialysis and peritoneal dialysis (PD). We report our exploratory study on the characteristics of intestinal microbiota and nutritional status in PD patients. The nutritional status of our PD patients were evaluated, and their feces were collected for 16S rRNA gene V3-V4 regions amplification and high-throughput sequencing. The characteristics and differences of microbiota between the well-nourished (W) and malnourished (M) groups were compared. We studied the genera and the operational taxonomic units (OTUs) within the genus of our patients, initially comparing the malnourished and the well- nourished groups and later on reanalyzing the whole group using these OTUs. At the OTU level, 6 bacteria were significantly correlated with the serum albumin level. The abundances of 2 OTUs (OTU208 Lachnospiraceae_incertae_sedi and OTU4 Bacteroides) were more in W group. Meanwhile, 4 OTUs (OTU225 Akkermansia, OTU87 Megasphaera, OTU31 Peptostreptococcaceae_incertae_sedi and OTU168 Clostridium_sensu_strictu) displayed higher abundance among individuals in M group. Notably, the OTU168 Clostridium_sensu_stricto was the only bacteria that significantly correlated with serum albumin (r = - 0.356, P = 0.05), pre-albumin (r = - 0.399, P = 0.02), and SGA (r = 0.458, P = 0.01). The higher the OTU168 Clostridium_sensu_strictu, the lower serum albumin and pre-albumin and a higher score of SGA signifying a worse nutritional status. Our preliminary findings suggested a relationship between the nutrition status and microbiota in PD patients. Our results provide a basis for further exploration of the interactions between malnutrition and intestinal flora in PD patients with potential interventions using probiotics and prebiotics.

Chronic kidney disease and dialysis therapy: incidence and prevalence in the world

Сhronic kidney disease (CKD) is the important public and medical problem in the world because of a large burden on health care systems. The prevalence of CKD and number of dialysis patients are increasing in the world. The prevalence and incidence of CKD depends on age, race, and gender of patients, region, and the presence of the CKD registry in a country. Diabetes mellitus (DM) and arterial hypertension (AH) are the most common causes of end stage renal disease (ESRD). It is projected that the number of dialysis patients will reach 5.5 million in 2030. Specific strategies and interventions should be urgently aimed at reducing in the burden of CKD by means of the prevention, detection and treatment of DM, AH, and early stages of CKD. One more strategy is the organization of own domestic manufacture of solutions for dialysis therapy.

Fatigue in Peritoneal Dialysis Patients and an Exploration of Contributing Factors: A Cross-Sectional Study

CONTEXT

Fatigue is a common and detrimental symptom in dialysis patients; however, our understanding of it and investigation of its contributing factors is still very limited, especially in peritoneal dialysis (PD) patients.

OBJECTIVES

To assess fatigue in PD patients and identify contributing factors.

METHODS

One hundred eight PD patients in a comprehensive hospital in China were recruited. The fatigue severity of the participants was assessed using the Chalder Fatigue Scale 11. Demographic factors and results of physiological tests were collected. Quality of sleep, mental health, and social support were assessed with the Pittsburgh Sleep Quality Index, Symptom Checklist 90, and Social Support Rating Scale, respectively. Multiple linear regression models were conducted with candidate variables with a P-value of less than 0.1 on univariate analysis and variables that were clinically relevant to identify contributing factors for fatigue.

RESULTS

The fatigue level in PD patients was significantly higher than the community population, and 78.7% of them were suffering from fatigue. The factors that were significantly associated with fatigue were quality of sleep, normalized protein nitrogen appearance, transferrin, alkaline phosphatase, and total cholesterol (adjusted R squared 0.86). Among them, quality of sleep, transferrin, alkaline phosphatase, and total cholesterol were significant contributors for physical fatigue, whereas the quality of sleep and normalized protein nitrogen appearance were contributing factors for mental fatigue.

CONCLUSION

Fatigue is a common symptom in PD patients, suggesting that increased awareness of this symptom is required. The identification of correlates by extensive exploration of multidimensional factors in this study may help practitioners to identify patients at higher risk and to develop a multidimensional and targeted intervention plan.

Peritoneal Dialysis-Associated Peritonitis

Peritonitis is a common and severe complication in peritoneal dialysis (PD). Detailed recommendations on the prevention and treatment of PD-associated peritonitis have been published by the International Society for Peritoneal Dialysis (ISPD), but there is a substantial variation in clinical practice among dialysis units. Prophylactic antibiotics administered before PD catheter insertion, colonoscopy, or invasive gynecologic procedures, daily topical application of antibiotic cream or ointment to the catheter exit site, and prompt treatment of exit site or catheter infection are key measures to prevent PD-associated peritonitis. When a patient on PD presents with clinical features compatible with PD-associated peritonitis, empirical antibiotic therapy, with coverage of both Gram-positive and Gram-negative organisms (including Pseudomonas species), should be started once the appropriate microbiologic specimens have been obtained. Intraperitoneal is the preferred route of administration. Antifungal prophylaxis, preferably oral nystatin, should be added to prevent secondary fungal peritonitis. Once the PD effluent Gram stain or culture and sensitivity results are available, antibiotic therapy can be adjusted accordingly. A detailed description on the dosage of individual antibiotic can be found in the latest recommendations by the ISPD. The duration of antibiotics is usually 2-3 weeks, depending on the specific organisms identified. Catheter removal and temporary hemodialysis support is recommended for refractory, relapsing, or fungal peritonitis. In some patients, a new PD catheter could be inserted after complete resolution of the peritonitis. PD catheter removal should also be considered for refractory exit site or tunnel infections. After the improvement in clinical practice, there is a worldwide trend of reduction in PD-associated peritonitis rate, supporting the use of PD as a first-line dialysis modality.

An international Delphi survey helped develop consensus-based core outcome domains for trials in peritoneal dialysis

Shared decision-making about clinical care options in end-stage kidney disease is limited by inconsistencies in the reporting of outcomes and the omission of patient-important outcomes in trials. Here we generated a consensus-based prioritized list of outcomes to be reported during trials in peritoneal dialysis (PD). In an international, online, three-round Delphi survey, patients/caregivers and health professionals rated the importance of outcomes using a 9-point Likert scale (with 7-9 indicating critical importance) and provided comments. Using a Best-Worst Scale (BWS), the relative importance of outcomes was estimated. Comments were analyzed thematically. In total, 873 participants (207 patients/caregivers and 666 health professionals) from 68 countries completed round one, 629 completed round two and 530 completed round three. The top outcomes were PD-related infection, membrane function, peritoneal dialysis failure, cardiovascular disease, death, catheter complications, and the ability to do usual activities. Compared with health professionals, patients/caregivers gave higher priority to six outcomes: blood pressure (mean difference, 0.4), fatigue (0.3), membrane function (0.3), impact on family/friends (0.1), peritoneal thickening (0.1) and usual activities (0.1). Four themes were identified that underpinned the reasons for ratings: contributing to treatment longevity, preserving quality of life, escalating morbidity, and irrelevant and futile information and treatment. Patients/caregivers and health professionals gave highest priority to clinical outcomes. In contrast to health professionals, patients/caregivers gave higher priority to lifestyle-related outcomes including the impact on family/friends and usual activities. Thus, prioritization will inform a core outcome set to improve the consistency and relevance of outcomes for trials in PD.

Urgent-Start Peritoneal Dialysis as a Bridge to Definitive Chronic Renal Replacement Therapy: Short- and Long-Term Outcomes

Background: The peritoneal dialysis (PD) urgent-start pathway, without typical 2-week break-in period, was meant for late-referral patients able and prone to join PD-first program, with its main advantages such as: keeping the vascular system intact, preserving their residual renal function and retaining life-style flexibility. We compared the short- and long-term outcomes of consecutive 35 patients after urgent- and 94 patients after the planned start of PD as the first choice.

Methods: The study included all incident end-stage renal disease patients starting PD program between January 2005 and December 2015, classified into two groups: those with urgent (unplanned) and those with elective (planned) start. Urgent PD was initiated as an overnight automatic procedure (APD) with dwell volume gradually increased, and after 2–3 weeks, target PD method was established.

Results: The mean time between catheter implantation and PD start was 3.5 ± 2.3 in urgent and 16.2 ± 1.7 days in planned-start groups (p < 0.00001). 51% of the patients in the urgent-start group required PD during first 48 h after catheter insertion. Mean follow-up of 17.6 ± 11.09 months (median: 19.0) was in the urgent-start group and 28.6 ± 26.6 months (median: 19.5) in the planned-start group. The early mechanical complications were observed more often in the urgent-start group (29 vs. 4%, p = 0.00005). The only significant predictors of early mechanical complications were serum albumin (p = 0.02) and time between the catheter insertion and PD start. The first year patient survival and technique survival censored for death and kidney transplantation were not significantly different between groups. In Cox proportional analysis the independent risk factors for patient survival as well as for method and patient survival appeared Charlson Comorbidity Index CCI (HR 1.4; p = 0.01 and 1.24; p = 0.02) and time from catheter implantation to PD start with HR 5.11; p = 0.03 and 4.29; p = 0.04 for <2 days, while time >14 days lost its predictive value (p = 0.07).

Conclusion: Peritoneal dialysis may be a feasible and safe alternative to HD in patients who need to start dialysis urgently without established dialysis access, with an acceptable complications rates, as well as patient and technique survival.

Hemodialysis or Peritoneal Dialysis, Which Is Better for Patients with Delayed Graft Function?

BACKGROUND/AIMS

Hemodialysis (HD) or peritoneal dialysis (PD) is an important renal replacement method in patients with delayed graft function (DGF) after kidney transplantation; however, it is not clear which dialysis modality is superior. This study determined the impact of different dialysis modalities on patients with DGF.

METHODS

It was a single-center, retrospective and descriptive study. We performed 673 kidney transplants from donors after cardiac death (DCD) between January 2010 and December 2016 at our center and 138 (20.5%) recipients developed DGF after transplantation. We classified the recipients into two groups according to post-transplant dialysis: DGF-HD (n=96) and DGF-PD (n=42). We analyzed the outcomes of the different dialysis modalities 30 days and 1 year post-transplantation.

RESULTS

There were no differences in baseline factors between patients with post-transplant HD (n = 96) or PD (n = 42). There were 10 patients with conversion from PD to HD during DGF. The DGF-PD patients had a higher rate of treatment failure than the DGF-HD patients (23.8% vs. 0%, p < 0.001), peritonitis (7.1% vs. 0%, p = 0.027), and longer duration of dialysis dependence (10.5 vs. 9 days, p = 0.003). There was no statistically significant difference between both groups with respect to acute rejection, hemorrhage, and patient and graft survival at 1 year.

CONCLUSION

In renal transplant recipients with DGF, post-transplant PD led to increased treatment failure. PD did not result in rapid recovery of transplanted renal function, and had a high probability of peritonitis.