Influence of autonomy and type of home assistance on the prevention of peritonitis in assisted automated peritoneal dialysis patients. An analysis of data from the French Language Peritoneal Dialysis Registry

Analysis of a nurse-provided on-call peritoneal dialysis support in an outpatient reference care centre

BACKGROUND

To analyse the nature of medical or technical emergency issues of ambulatory peritoneal dialysis (PD) patients calling a nurse-provided emergency PD support service of a reference centre that is provided all year in the after-hours.

METHODS

We retrospectively analysed patients' chief complaint, urgency, resolution of and association to current PD treatment and modality directed to an on-call nurse-provided PD support service from 2015-2021 based on routinely collected health data. Calls were systematically categorized being technical/procedural-, medical-, material-related or type of correspondence. Call urgency was categorized to have "immediate consequence", inquiry was eligible for "processing next working day" or whether there was "no need for further action". Call outcomes were classified according to whether patients were able to initiate, resume or finalize their treatments or whether additional interventions were required. Unexpected adverse events such as patients' acute hospitalization or need for nurses' home visits were evaluated and quantified.

RESULTS

In total 753 calls were documented. Most calls were made around 7:30 a.m. (5:00-9:00; median, 25-75th CI) and 6:30 p.m. (5:00-8:15). 645 calls were assigned to continuous ambulatory- (CAPD) or automated PD (APD). Of those, 430 calls (66.7%) had an "immediate consequence". Of those 77% (N = 331) were technical/procedural-, 12.8% (N = 55) medical- and 6.3% (N = 27) material related issues. 4% (N = 17) were categorized as other correspondence. Issues disrupting the course of PD were identified in 413 cases. In 77.5% (N = 320) patients were able to initiate, resume or finalize their treatment after phone consultation. Last-bag exchange was used in 6.1% enabling continued therapy in 83.6%. In 35 cases a nurse visit at patients' home or patients' visit to the practice at the earliest possible date were required, while hospitalization was required in seven medical category cases (5.4% and 1.09% of total assessed calls, respectively).

CONCLUSION

The on-call PD-nurse provides patient support for acute and imminent issues enabling them to successfully initiate, resume or finalize their prescribed treatment. Nurses triage of acute conditions facilitated rapid diagnostics and therapy. Maintaining quality PD homecare, the provision of trained personnel is indispensable. The information gathered in this study may therefore be used as a foundation to tailor educational programs for nephrology nurses and doctors to further develop their competencies in PD.

The optimization of peritoneal dialysis training in long-term

Peritoneal dialysis is a home based therapy for patients with advanced chronic kidney disease. This method provides adequate clearance of uremic toxins and removal of excess fluid when a proper dialysis prescription is combined with patient adherence. Peritonitis is the most frequent infectious complication among these patients and may render the continuity of the treatment. Training patients and their caregivers have prime importance to provide proper treatment and prevent complications including infectious ones. The training methods before the onset of treatment are relatively well established. However, patients may break the rules in the long term and tend to take shortcuts. So, retraining may be necessary during follow-up. There are no established guidelines to guide the retraining of PD patients yet. This review tends to summarize data in the literature about retraining programs and also proposes a structured program for this purpose.

Assisted peritoneal dialysis performed by caregivers and its association with patient outcomes

BACKGROUND

Although caregivers allow peritoneal dialysis (PD) patients with disabilities the opportunity to perform PD, it is crucial to clarify the safety and effectiveness of assisted PD performed by caregivers compared to self-PD.

METHODS

PD patients from 22 PD centres in Thailand were prospectively followed in the Peritoneal Dialysis Outcomes and Practice Patterns Study during 2016-2017. Patients receiving assisted PD performed by caregivers were matched 1:1 with self-PD patients using propensity scores calculated by logistic regression. The associations between assisted PD and risk of mortality, peritonitis and permanent transfer to haemodialysis (HD) were assessed by multivariable competing risk regression.

RESULTS

Of 778 eligible patients, 447 (57%) required assisted PD performed by caregivers. Most of the caregivers were family members (98%), while the rest were non-family paid caregivers (2%). Patient factors associated with assisted PD were older age, female gender, lower educational level, cardiovascular comorbidities, diabetes, automated PD modality, poorer functional status and lower blood chemistries (albumin, creatinine, sodium, potassium and phosphate). After 1:1 matching, the baseline characteristics were adequately matched, and 269 patients in each group were analysed. Compared with self-PD, assisted PD was significantly associated with an increased risk of all-cause mortality (adjusted sub-hazard ratio: 2.15, 95% confidence interval: 1.24-3.74). There were no differences in the occurrences of peritonitis and permanent HD transfer between the groups.

CONCLUSIONS

Assisted PD was required by more than half of Thai PD patients and was independently associated with a higher mortality risk. This may reflect causal effect or confounding by indication.

Availability of assisted peritoneal dialysis in Europe: call for increased and equal access

INTRODUCTION

Availability of assisted PD (asPD) increases access to dialysis at home, particularly for the increasing numbers of older and frail people with advanced kidney disease. Although asPD has been widely used in some European countries for many years, it remains unavailable or poorly utilised in others. A group of leading European nephrologists have therefore formed a group to drive increased availability of asPD in Europe and in their own countries.

METHODS

Members of the group filled in a proforma with the following headings: personal experience, country experience, who are the assistants, funding of asPD, barriers to growth, what is needed to grow, and their top 3 priorities.

RESULTS

Only 5 of the 13 countries surveyed provided publicly funded reimbursement for asPD. The use of asPD depends on overall attitudes to PD with all respondents mentioning need for nephrology team education and/or patient education and involvement in dialysis modality decision making.

CONCLUSION AND CALL TO ACTION

Many people with advanced kidney disease would prefer to have their dialysis at home, yet if the frail patient chooses PD most healthcare systems cannot provide their choice. AsPD should be available in all countries in Europe and for all renal centres. The top priorities to make this happen are education of renal healthcare teams about the advantages of PD, education of and discussion with patients and their families as they approach the need for dialysis, and engagement with policy makers and healthcare providers to develop and support assistance for PD.

Costs of Assisted Home Dialysis: A Single-Payer Canadian Model From Manitoba

Rationale & Objective

The prevalence of kidney failure is increasing globally. Most of these patients will require life-sustaining dialysis at a substantial cost to the health care system. Assisted peritoneal dialysis (PD) and assisted home hemodialysis (HD) are potential alternatives to in-center HD and have demonstrated equivalent outcomes with respect to mortality and morbidity. We aim to describe the costs associated with assisted continuous cycling PD (CCPD) and assisted home HD.

Study Design

Cost minimization model.

Setting & Population

Adult incident maintenance dialysis patients in Manitoba, Canada.

Intervention

Full- and partial-assist home HD and CCPD. Full-assist modalities were defined as nurse-assisted dialysis setup and takedown performed by a health care aide, whereas partial-assist modalities only included nurse-assisted setup. Additionally, full-assist home HD was evaluated under a complete care scenario with the inclusion of a health care aide remaining with the patient throughout the duration of treatment.

Outcomes

Annual per-patient maintenance and training costs related to assisted and self-care home HD and CCPD, presented in 2019 Canadian dollars.

Model, Perspective, & Time Frame

This model took the perspective of the Canadian public health payer using a 1-year time frame.

Results

Annual total per-patient maintenance (and training) costs by modality were the following: full-assist CCPD, $75.717 (initial training costs, $301); partial-assist CCPD, $67,765 ($4,385); full-assist home HD, $47,862 ($301); partial-assist home HD, $44,650 ($14,813); and full-assist home HD (complete care), $64,659 ($301).

Limitations

This model did not account for costs taken from the societal perspective or costs related to PD failure and modality switching. Additionally, this analysis reflects only costs experienced by a single center.

Conclusions

Assisted home-based dialysis modalities are viable treatment options for patients from a cost perspective. Future studies to consider graduation rates to full self-care from assisted dialysis and the cost implications of respite care are needed.

International peritoneal dialysis training practices and the risk of peritonitis

BACKGROUND

The effects of training practices on outcomes of patients receiving peritoneal dialysis (PD) are poorly understood and there is a lack of evidence informing best training practices. This prospective cohort study aims to describe and compare international PD training practices and their association with peritonitis.

METHODS

Adult patients on PD < 3 months participating in the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) were included. Training characteristics (including duration, location, nurse affiliation, modality, training of family members, use of individual/group training, and use of written/oral competency assessments) were reported at patient and facility levels. Hazard ratio for time to first peritonitis was estimated using Cox models, adjusted for selected patient and facility case-mix variables.

RESULTS

1376 PD patients from 120 facilities across 7 countries were included. Training was most commonly performed at the facility (81%), by facility-affiliated nurses (87%) in a 1:1 setting (79%). In the UK, being trained by both facility and third-party nurses was associated with reduced peritonitis risk (aHR 0.31, 95% CI 0.15-0.62, vs facility nurses only). However, this training practice was utilized in only 5 of 14 UK facilities. No other training characteristics were convincingly associated with peritonitis risk.

CONCLUSIONS

There was no evidence to support that peritonitis risk was associated with when, where, how, or how long PD patients are trained.

Good practices for dialysis education, treatment, and eHealth: A scoping review

BACKGROUND

Recommendations regarding dialysis education and treatment are provided in various (inter)national guidelines, which should ensure that these are applied uniformly in nephrology and dialysis centers. However, there is much practice variation which could be explained by good practices: practices developed by local health care professionals, which are not evidence-based. Because an overview of good practices is lacking, we performed a scoping review to identify and summarize the available good practices for dialysis education, treatment, and eHealth.

METHODS

Embase, Pubmed, the Cochrane Library, CINAHL databases and Web of Science were searched for relevant articles using all synonyms for the words 'kidney failure', 'dialysis', and 'good practice'. Relevant articles were structured according to the categories dialysis education, dialysis treatment or eHealth, and assessed for content and results.

RESULTS

Nineteen articles (12 for dialysis education, 3 for dialysis treatment, 4 for eHealth) are identified. The good practices for education endorse the importance of providing complete and objective predialysis education, assisting peritoneal dialysis (PD) patients in adequately performing PD, educating hemodialysis (HD) patients on self-management, and talking with dialysis patients about their prognosis. The good practices for dialysis treatment focus mainly on dialysis access devices and general quality improvement of dialysis care. Finally, eHealth is useful for HD and PD and affects both quality of care and health-related quality of life.

CONCLUSION

Our scoping review identifies 19 articles describing good practices and their results for dialysis education, dialysis treatment, and eHealth. These good practices could be valuable in addition to guidelines for increasing shared-decision making in predialysis education, using patients' contribution in the implementation of their dialysis treatment, and advanced care planning.

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.

Effectiveness of a continuous interactive communication system for home care nursing assistance of peritoneal dialysis

Background

The Japanese population is aging quickly. New methods of supporting peritoneal dialysis (PD) for elderly patients are essential if we are to increase the number of such patients.

Methods

We established a two-way communication system between a central hospital and stations for visiting nurses. Home care nurses provided physicians at the central hospital with clinical findings for patients undergoing assisted PD. We compared 11 patients undergoing PD assisted by home care nurses in continuous interactive communication with the central hospital (cases) with 11 patients undergoing unassisted PD who were matched by sex, primary disease, estimated glomerular filtration rate at the start of PD, and age at the start of PD (controls). The variables compared were hospitalization due to heart failure, exit-site infection, peritonitis, and the composite of these causes during a 1-year period. In addition, we compared patient clinical factors between groups.

Results

Although differences in the number of hospitalizations attributable to exit-site infection, peritonitis, and heart failure were not significant, the difference in the number of hospitalizations attributable to a composite of these causes was significant. Exit-site scores were significantly better in the case group than in the control group.

Conclusions

PD assisted by home care nurses using an established continuous interactive communication system was associated with significantly better exit-site scores. Fewer cases than controls were hospitalized.

Trends in Peritoneal Dialysis Technique Survival, Death, and Transfer to Hemodialysis: A Decade of Data from the RDPLF

INTRODUCTION

There is limited information on the trends of peritoneal dialysis (PD) technique survival over time. This study aimed to estimate the effect of calendar time on technique survival, transfer to hemodialysis (HD) (and the individual causes of transfer), and patient survival.

METHODS

This retrospective, multicenter study, based on data from the French Language Peritoneal Dialysis Registry, analyzed 14,673 patients who initiated PD in France between January 1, 2005, and December 31, 2016. Adjusted Cox regressions with robust variance were used to examine the probability of a composite end point of either death or transfer to HD, death, and transfer to HD, accounting for the nonlinear impact of PD start time.

RESULTS

There were 10,201 (69.5%) cases of PD cessation over the study period: 5,495 (37.4%) deaths and 4,706 (32.1%) transfers to HD. The rate of PD cessation due to death or transfer to HD decreased over time (PR 0.96, 95% CI: 0.95-0.97). Compared to 2009-2010, starting PD between 2005 and 2008 or 2011 and 2016 was strongly associated with a lower rate of transfer to HD (PR 0.88, 95% CI: 0.81-0.96, and PR 0.91, 95% CI: 0.84-0.99, respectively), mostly due to a decline in the rate of infection-related transfers to HD (PR 0.96, 95% CI: 0.94-0.98).

CONCLUSIONS

Rates of the composite end point of either death or transfer to HD, death, and transfer to HD have decreased in recent decades. The decline in transfers to HD rates, observed since 2011, is mainly the result of a significant decline in infection-related transfers.

Incidence and risk factors of peritoneal dialysis-related peritonitis in elderly patients: A retrospective clinical study

BACKGROUND

This study was to analyze the incidence, risk factors, and clinical outcomes of peritonitis in elderly continuous ambulatory peritoneal dialysis (CAPD) patients.

METHODS

Incident patients undergone CAPD from 1 January 2006 to 30 June 2015 in our center were enrolled and divided into aged < 65 years and ≥ 65 years groups. Risk factors were evaluated using a logistic regression model, and outcome comparison was evaluated using a Cox proportional model.

RESULTS

Among 1953 patients, 111(33.2%) in elderly (n = 334) and 470 (29.0%) in younger (n = 1619) developed at least one episode of peritonitis. Comparing with younger patients, elderly ones had a higher peritonitis rate (0.203 vs. 0.145 episodes/patient-year, p < 0.05). The multivariate Cox regression showed that advanced age (hazard ratio (HR) = 1.06, 95% confidence interval (CI) = 1.01-1.11, p = 0.015), assistant-assisted peritoneal dialysis (PD; HR = 2.64, 95% CI = 1.23-5.64, p = 0.012), higher body mass index (BMI; HR = 1.11, 95% CI = 1.02-1.20, p = 0.010), and low serum albumin level (HR = 0.94, 95% CI = 0.90-0.98, p = 0.004) were associated with increased peritonitis risk in elderly patients. Compared with younger ones with peritonitis, elderly patients had an approximately fourfold increased risk of peritonitis-related mortality (odd ratio (OR) = 3.57, 95% CI = 1.38-9.28, p = 0.009). During the cohort, peritonitis was the risk factor associated with technique failure (HR = 3.19, 95% CI = 2.33-4.39, p < 0.001) in younger patient but not in the elderly population (HR = 1.82, 95% CI = 0.84-3.94, p = 0.132).

CONCLUSIONS

Elderly PD patients had higher prevalence for peritonitis and peritonitis-related mortality. Advanced age, assistant-assisted PD, a higher BMI, and lower serum albumin level were independently associated with the first episode of peritonitis in elderly patients. However, peritonitis was not the predictor of death-censored technique failure in elderly ones.

Helper-assisted continuous ambulatory peritoneal dialysis: Does the choice of helper matter?

BACKGROUND

There is an increasing number of elderly patients on continuous ambulatory peritoneal dialysis (CAPD) who could not perform dialysis exchange themselves and require assistance. We examine the outcome of Chinese CAPD patients who required helper-assisted dialysis and compare the outcome between different types of helper.

METHODS

We reviewed 133 incident patients on helper-assisted CAPD and 266 incident patients who performed self-CAPD exchanges (self-peritoneal dialysis (PD) group). Outcome measures included patient survival, peritonitis-free survival, and overall peritonitis rate.

RESULTS

At 24 months, patient survival of the helper-assisted and self-PD groups were 56.0% and 80.6%, respectively (p < 0.0001). Within the helper-assisted group, patient survival at 24 months was 55.5%, 63.2%, and 27.2% for the patients with domestic helper, family member, and nursing home staff as their helpers, respectively (p = 0.037). Peritonitis-free survival of the helper-assisted and self-PD groups were 54.2% and 64.9%, respectively (p = 0.039). Within the helper-assisted group, peritonitis-free survival at 24 months was 59.4%, 55.4%, and 37.2% for the patients with domestic helper, family member, and nursing home staff as their helpers, respectively (p = 0.06). There was no significant difference in peritonitis rate between patients with domestic helper, family member, and nursing home staff as their helpers (0.54, 0.57, and 0.94 episodes per patient-year, respectively, p = 0.2).

CONCLUSIONS

Helper-assisted CAPD patients had worse patient survival and peritonitis-free survival than the self-PD group. Assistance by nursing home staff was associated with worse patients' survival and peritonitis-free survival than assistance by family members or domestic maids.

Barriers to Peritoneal Dialysis in Saskatchewan Canada: Results From a Province-Wide Survey

Background:

Peritoneal dialysis (PD) is an underutilized, therapeutic option to in-center hemodialysis (HD), given its similar survival and clinical efficacy but provides lifestyle benefits and cost savings. Despite these advantages, PD prevalence rates remains below 20% in many Canadian jurisdictions.

Objectives:

The primary objective of this study was to identify and assess patient-perceived barriers to PD implementation in Saskatchewan. The secondary objectives were to examine variations in patient-perceived barriers to PD by dialysis units (main dialysis units vs satellite dialysis units) and specific challenges faced by First Nation patients residing on reserves.

Design:

A cross-sectional observational survey study.

Setting:

Two major centers (Regina and Saskatoon) and 5 associated satellite units attached to each center across the province of Saskatchewan.

Patients:

We approached all prevalent in-center HD patients across Saskatchewan, 366 (49%) agreed to participate in the study.

Measurements:

Self-reported barriers to PD were assessed using a 26-question survey which was created after engagement of our multidisciplinary team.

Methods:

We conducted a cross-sectional survey of 740 prevalent in-center HD patients within the province of Saskatchewan, Canada, from June 2018 to January 2019. Around 366 (49%) patients agreed to participate in the study. The questionnaire was designed to capture patients’ perceived barriers to PD. Descriptive statistics were used to present the data. Chi-square and Mann-Whitney U-test were used to compare the patients’ responses (main dialysis units vs satellite dialysis units, and First Nation reserves vs nonreserves).

Results:

Of the 366 patients who completed the survey, 284 met the eligibility criteria and were included in the analysis. Patient-reported satisfaction with current in-center HD care was the most common barrier to PD uptake (92%), followed by proximity to their HD unit (61%). A lack of understanding of the benefits/risks of PD, fear of family burden (54% each), and unwillingness to dialyze daily and to learn a new technique (51% each) were additional factors. Patients residing on reserves compared to nonreserve residents felt PD had a higher risk of infection compared to HD (54% vs 34%, P = .005), and felt PD led to suboptimal care (47% vs 31%, P = .021).

Limitations:

We used a nonstandardized locally derived questionnaire to quantify barriers, and this prevents inclusion of additional barriers than individual patients may consider important. Cross-sectional data can only be used as a snapshot. Only 366 patients agreed to participate, and the results cannot be generalized to 740 prevalent HD patients. We did not capture data on demographics (age, income, and literacy level), comorbidities, and dialysis vintage, which would have been helpful in interpretation of the results. We did not involve patients, carers, or patients of First Nations heritage, in the design of the survey and the study.

Conclusions:

The results of our survey indicate that the major patient-reported barrier to PD uptake in our province is clinical inertia in patients defaulted to in-center HD at the onset of dialysis. Lack of patient awareness and knowledge of PD as a viable treatment modality also figured prominently, as did fears/concerns surrounding the safety, efficacy, and perceived family burden with PD compared with in-center HD.

Trial Registration:

The study was not registered on a publicly accessible registry because it did not involve any health care intervention on human participants.

Facilitators and Barriers to Care in Rural Emergency Departments in Alberta for Patients on Peritoneal Dialysis (PD): An Interpretive Descriptive Study

Background:

Home dialysis offers many advantages to patients, but they require support to manage a home-based therapy such as peritoneal dialysis (PD). A rural emergency department provides an important safety net for patients requiring medical care, including managing complications of PD, such as peritonitis. Patients living in northern Alberta are spread out geographically and can be far from a PD training center, yet anecdotally, many rural sites do not provide care for these patients.

Objective:

Our aim was to identify the facilitators and barriers to nursing care in rural emergency departments in northern Alberta for patients receiving PD.

Design:

A qualitative interpretive descriptive approach was used.

Setting:

Rural emergency departments across northern Alberta.

Participants:

Purposeful sampling was used to seek participants from 1 of 4 rural acute care hospital emergency departments in northern Alberta. Six registered nurses and 1 licensed practical nurse agreed to participate in the study. They ranged in experience from 2 to 18 years. Two of the participants were unit managers, 2 were clinical nurse educators (CNEs), and the other 3 were staff nurses with 1 of them in a leadership position.

Methods:

Individual semistructured interview were conducted over the telephone. The interview guide was developed based on a review of the literature. Interviews continued until no new information was obtained, that is, data were saturated. Interviews were audio recorded and transcribed verbatim. Field notes were recorded. A constant comparative approach was used for analysis. The coding process was both deductive (drawing from the literature) and inductive.

Results:

Seven participants were interviewed, and there were 4 main themes and 1 subtheme that emerged from the analysis: education (along with the subtheme of resources) was seen as both facilitators and barriers; patient/family ability to perform PD; infrequent exposure; and physician supports. Continuing education about PD was a facilitator, and the lack of education was a barrier to provision of PD care. Similarly, availability of resource materials about PD and access to a CNE were facilitators, while lack of these resources was a barrier to offering PD care. As PD was not always seen regularly, infrequent exposure was a barrier to offering PD care. Lack of physician supports, both from the locum physicians who were sometimes reluctant to care for these patients and the delays in reaching nephrologists were barriers.

Limitations:

The findings represent the perceptions of the emergency department nurses who participated. These perceptions may differ from those of nurses who work in other regions of the country. Furthermore, most participants were in a leadership role, and it may be that their perspectives differ from those of front-line nurses.

Conclusions:

The findings from our study highlight the need for availability of education and resource materials/persons to care for these patients. There is also a need for greater physician support from both local physicians as well as nephrologists to offer high-quality PD care.

Trial registration:

Not applicable. This study is not a clinical trial. It did not involve prospective assignment of participants to a treatment group.

A Systematic Review and Jurisdictional Scan of the Evidence Characterizing and Evaluating Assisted Peritoneal Dialysis Models

BACKGROUND AND OBJECTIVES

Compared with hemodialysis, home peritoneal dialysis alleviates the burden of travel, facilitates independence, and is less costly. Physical, cognitive, or psychosocial factors may preclude peritoneal dialysis in otherwise eligible patients. Assisted peritoneal dialysis, where trained personnel assist with home peritoneal dialysis, may be an option, but the optimal model is unknown. The objective of this work is to characterize existing assisted peritoneal dialysis models and synthesize clinical outcomes.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A systematic review of MEDLINE, Cochrane Central Register of Controlled Trails, Cochrane Database of Systematic Reviews, Embase, PsycINFO, and CINAHL was conducted (search dates: January 1995-September 2018). A focused gray literature search was also completed, limited to developed nations. Included studies focused on home-based assisted peritoneal dialysis; studies with the assist provided exclusively by unpaid family caregivers were excluded. All outcomes were narratively synthesized; quantitative outcomes were graphically depicted.

RESULTS

We included 34 studies, totaling 46,597 patients, with assisted peritoneal dialysis programs identified in 20 jurisdictions. Two categories emerged for models of assisted peritoneal dialysis on the basis of type of assistance: health care and non-health care professional assistance. Reported outcomes were heterogeneous, ranging from patient-level outcomes of survival, to resource use and transfer to hemodialysis; however, the comparative effect of assisted peritoneal dialysis was unclear. In two qualitative studies examining the patient experience, the maintenance of independence was identified as an important theme.

CONCLUSIONS

Reported outcomes and quality were heterogeneous, and relative efficacy of assisted peritoneal dialysis could not be determined from included studies. Although the patient voice was under-represented, suggestions to improve assisted peritoneal dialysis included using a person-centered model of care, ensuring continuity of nurses providing the peritoneal dialysis assist, and measures to support patient independence. Although attractive elements of assisted peritoneal dialysis are identified, further evidence is needed to connect assisted peritoneal dialysis outcomes with programmatic features and their associated funding models.

Centre characteristics associated with the risk of peritonitis in peritoneal dialysis: a hierarchical modelling approach based on the data of the French Language Peritoneal Dialysis Registry

Background.

This study investigated the centre effect on the risk of peritonitis in peritoneal dialysis (PD) patients.

Methods.

This was a retrospective cohort study based on data from the French Language Peritoneal Dialysis Registry. We analysed 5017 incident patients starting PD between January 2008 and December 2012 in 127 PD centres. The end of the observation period was 1 January 2014. The event of interest was the first peritonitis episode. The analysis was performed with a multilevel Cox model and a Fine and Gray model.

Results.

Among the 5017 patients, 3190 peritonitis episodes occurred in 1796 patients. There was significant heterogeneity between centres (variance of the random effect: 0.11). The variance of the centre effect was reduced by 9% after adjusting for patient characteristics and by 35% after adjusting on centre covariate. In the multivariate analysis with a multilevel Cox model, centre with a nurse specialized in PD or centre providing home visits before dialysis initiation decreased the centre effect on peritonitis. Patients treated in centres with a nurse specialized in PD or in centres providing home visits before dialysis initiation had a lower risk of peritonitis [cause-specific hazard ratio (cs-HR): 0.75 (95% confidence interval, CI, 0.67-0.83) and cs-HR: 0.87 (95% CI 0.76-0.97), respectively]. The data show that neither centre type nor centre volume influenced peritonitis risk. In the competing risk analysis, centre with a nurse specialized in PD and centre with home visits had a protective effect on peritonitis [sub-distribution HR (sd-HR): 0.77 (95% CI 0.70-0.85) and sd-HR: 0.85 (95% CI 0.77-0.94), respectively].

Conclusion.

There is a significant centre effect on the risk of peritonitis that can be decreased by home visits before dialysis initiation and by the presence of a nurse specialized in PD.

Worldwide Experiences with Assisted Peritoneal Dialysis

End-stage renal disease (ESRD) is common in the elderly population, and renal replacement therapy (RRT) is often required. However, in this particular subgroup of patients, the choice between hemodialysis (HD) and peritoneal dialysis (PD) is often not an easy decision to make. Published literature has adequately demonstrated that PD prevalence is significantly less than HD across all patient age groups despite several advantages. We also know that elderly patients are less likely to complete a PD assessment, due to both medical and social barriers. Additionally, elderly patients are often reluctant to go ahead with PD despite being eligible PD candidates, mainly due to the fear of performing self-therapy. Recently, many new assisted PD (asPD) programs have cropped up in several countries. The main aim of these programs is to overcome barriers to PD and to promote PD utilization among elderly and non-self-sufficient patients. Although asPD has proven to be associated with good clinical results, there still remain concerns about its greater use. In this review, we will first describe an ideal asPD model and then enumerate examples of strategies and outcomes associated with successful asPD programs worldwide.

A contemporary approach to the prevention of peritoneal dialysis-related peritonitis in children: the role of improvement science

Peritonitis is a leading cause of hospitalizations, morbidity, and modality change in pediatric chronic peritoneal dialysis (CPD) patients. Despite guidelines published by the International Society for Peritoneal Dialysis aimed at reducing the risk of peritonitis, registry data have revealed significant variability in peritonitis rates among centers caring for children on CPD, which suggests variability in practice. Improvement science methods have been used to reduce a variety of healthcare-associated infections and are also being applied successfully to decrease rates of peritonitis in children. A successful quality improvement program with the goal of decreasing peritonitis will not only include primary drivers directly linked to the outcome of peritonitis, but will also direct attention to secondary drivers that are important for the achievement of primary drivers, such as health literacy and patient and family engagement strategies. In this review, we describe a comprehensive improvement science model for the reduction of peritonitis in pediatric patients on CPD.

Evaluation of A 12-Month Pilot of Long-Term and Temporary Assisted Peritoneal Dialysis

Background

Peritoneal dialysis (PD) is challenging for patients with functional limitations, and assisted PD can support these patients, but previous reports of assisted PD have not examined the role of temporary assisted PD and had difficulty identifying adequate comparator cohorts.

Methods

Peritoneal Dialysis Assist (PDA), a 12-month pilot of long-term and temporary assisted PD was completed in multiple PD centers in British Columbia, Canada. Continuous cycler PD (CCPD) patients were identified for PDA by standardized criteria, and service could be long-term or temporary/respite. The PDA program provided daily assistance with cycler dismantle and setup, but patients remained responsible for cycler connections and treatment decisions. Outcomes were compared against both the general CCPD population and patients who met PDA criteria but were not enrolled (PDA-eligible).

Results

Fifty-three PDA patients had an 88% 1-year death- and transplant-censored technique survival that was similar to the general CCPD cohort (84%) and PDA-eligible cohort (86%). The PDA cohort had lower peritonitis rates (0.18 episodes/patient-year vs 0.22 and 0.36, respectively), but higher hospitalization (55% vs 34% and 35%, respectively). Long-term PDA cost approximately CDN$15,000/year in addition to existing dialysis costs. A total of 8/11 respite PDA patients (73%) returned to self-care PD after a median PDA use of 29 days, which costs $1,250/patient.

Conclusions

Peritoneal Dialysis Assist provides effective support to functionally-limited CCPD patients and yields acceptable clinical outcomes. The program costs less than transfer to HD or long-term care, which represents cost minimization for failing self-care PD patients. Respite PDA provides effective temporary support; most patients returned to self-care PD and service was cost-effective compared with alternatives of hospitalization or transfer to HD.

Assisted Peritoneal Dialysis for Older People with End-Stage Renal Disease: The French and Danish Experience

Older people are the largest and fastest growing group of patients with end-stage renal disease (ESRD), and, due to advanced age and a heavy burden of comorbidities, they are usually not candidates for renal transplantation or home-based dialysis treatment. Some of the barriers for home treatment are non-modifiable, but the majority of physical disabilities and psychosocial problems can be overcome provided that assistance is offered to the patients at home.In the present review, we describe the programs for assisted peritoneal dialysis (PD) in France and Denmark, respectively. In both nations, assisted PD is totally publicly funded, and the cost of assisted PD is comparable to the cost of in-center HD. Assisted continuous ambulatory PD (aCAPD) is the preferred modality in France whereas assisted automated PD (aAPD) is the preferred modality in Denmark. Assistants are professional nurses or healthcare technicians briefly educated by expert PD nurses from the dialysis unit.The establishment of a program for assisted PD may increase the number of patients actually treated with PD and may reduce the risk of PD technique failure and prolong PD duration. Compared with autonomous PD patients, patients on assisted PD may have shorter patient survival and peritonitis-free survival indicating that, besides advanced age and the burden of comorbidities, dependency on help may be an independent risk factor for poorer outcome.Assisted PD is an evolving dialysis modality, and may in the future prove to be a feasible complementary alternative to in-center hemodialysis (HD) for the growing group of dependent older patients with ESRD.

Liver transplantation in transthyretin amyloidosis: Characteristics and management related to kidney disease

Orthotopic liver transplantation (LT) was implemented as the inaugural disease-modifying therapy for hereditary transthyretin (ATTR) amyloidosis, a systemic amyloidosis mainly affecting the peripheral nervous system and heart. The first approach to pharmacologic therapy was focused on the stabilization of the TTR tetramer; following that new advent LT was assumed as the second step of treatment, for those patients whose neuropathy becomes worse after a course of pharmacologic therapy. The renal disease has been ignored in hereditary ATTR amyloidosis. The low level of proteinuria or slight renal impairment does not suppose such a heavy glomerular and vascular amyloid deposition. Moreover, severity of renal deposits does not consistently parallel that of myelinated nerve fiber loss. These are pitfalls that limit the success of LT and suggest troublesome criteria for pharmacological therapy or LT. An algorithm of evaluation concerning renal disease and treatment options is presented and some bridges-to-decision are exposed. In stage 4 or 5 kidney disease, the approach remains to deliver combined or sequential liver-kidney transplantation in eligible patients. However, in the majority, hemodialysis is the only option even in the presence of a well-functioning liver graft. In this review, we highlight useful information to aid the transplant hepatologist in the clinical practice.

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.

The Current State of Peritoneal Dialysis

Technical innovations in peritoneal dialysis (PD), now used widely for the long-term treatment of ESRD, have significantly reduced therapy-related complications, allowing patients to be maintained on PD for longer periods. Indeed, the survival rate for patients treated with PD is now equivalent to that with in-center hemodialysis. In parallel, changes in public policy have spurred an unprecedented expansion in the use of PD in many parts of the world. Meanwhile, our improved understanding of the molecular mechanisms involved in solute and water transport across the peritoneum and of the pathobiology of structural and functional changes in the peritoneum with long-term PD has provided new targets for improving efficiency and for intervention. As with hemodialysis, almost half of all deaths on PD occur because of cardiovascular events, and there is great interest in identifying modality-specific factors contributing to these events. Notably, tremendous progress has been made in developing interventions that substantially reduce the risk of PD-related peritonitis. Yet the gains have been unequal among individual centers, primarily because of unequal clinical application of knowledge gained from research. The work to date has further highlighted the areas in need of innovation as we continue to strive to improve the health and outcomes of patients treated with PD.

The Association Between Glucose Exposure and the Risk of Peritonitis in Peritoneal Dialysis Patients

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BACKGROUND AND OBJECTIVE

Little or no clinical evidence is available on the association between glucose exposure and peritoneal host defense in peritoneal dialysis (PD) patients. The objective of the present study was to quantify the exposure to glucose during the first year on PD and investigate the association with subsequent peritonitis. ♦

METHODS

We analyzed prospectively collected demographic and peritonitis data from incident adult PD patients between 1990 and 2010. For the present study, we conducted a review of both in- and outpatient medical records of all patients to obtain their day-to-day dialysis schemes during the first year on PD. From these data, the average exposure to glucose was quantified. The exposure was stratified into low- and high-glucose groups based on the median, analyzed per standard deviation and in quartiles. Cox proportional hazard models were used to calculate crude and adjusted hazard ratios (HRs) and 95% confidence intervals for the association between glucose exposure and peritonitis. Adjustments were made for age, sex, primary kidney disease, diabetes mellitus, Davies comorbidity score and the treatment period. ♦

RESULTS

In total, 230 patients were included in the study of whom 151 (66%) experienced a first peritonitis episode. The median follow-up time was 2.6 years (interquartile range [IQR]: 1.9 - 3.8) in the low-glucose group and 3.1 (IQR: 2.1 - 4.2) in the high-glucose group. After adjustment for confounding factors, no association between high glucose exposure and the risk of peritonitis was found (HR: 0.81; 0.55 - 1.17). No association was present when glucose exposure was analyzed per standard deviation (SD) (HR: 0.98; 0.79 - 1.21) or patient quartiles were applied. No association was identified between glucose exposure and severe peritonitis, Staphylococcus aureus peritonitis, or a peritonitis episode that lasted more than 14 days. ♦

CONCLUSIONS

Exposure to glucose is not associated with an increased risk of peritonitis. The equilibrium between glycemic harm to peritoneal host defense and detrimental effects of glucose on invading microorganisms may determine the susceptibility to peritoneal infection.

Estimation of the Center Effect on Early Peritoneal Dialysis Failure: A Multilevel Modelling Approach

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INTRODUCTION

This study was carried out to investigate the center effect on the risk of peritoneal dialysis (PD) failure within the first 6 months of therapy using a multilevel approach. ♦

METHODS

This was a retrospective cohort study based on data from the French Language Peritoneal Dialysis Registry. We analyzed 5,406 incident patients starting PD between January 2008 and December 2012 in 128 PD centers. The end of the observation period was December 31, 2013. ♦

RESULTS

Of the 5,406 patients, 415 stopped PD within the first 6 months. There was a significant heterogeneity between centers (variance of the random effect: 0.10). Only 3% of the variance of the event of interest was attributable to differences between centers. At the individual level, only treatment before PD (odds ratio [OR]: 1.93 for hemodialysis and OR: 2.29 for renal transplantation) and underlying nephropathy (p < 0.01) were associated with early PD failure. At the center level, only center experience was associated (OR: 0.78) with the risk of PD failure. Center effect accounted for 52% of the disparities between centers. ♦

CONCLUSION

Center effect on early PD failure is significant. Center experience is associated with a lower risk of transfer to hemodialysis.

Is Peritonitis Risk Increased in Elderly Patients on Peritoneal Dialysis? Report from the French Language Peritoneal Dialysis Registry (RDPLF)

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INTRODUCTION

This study was carried out to examine whether or not elderly patients on peritoneal dialysis (PD) had an increased risk of peritonitis. ♦

METHODS

This was a retrospective cohort study based on data from the French Language Peritoneal Dialysis Registry. We analyzed 8,396 incident patients starting PD between January 2003 and December 2010. The end of the observation period was 31 December 2012. Patients were separated into 2 age groups: up to 75 and over of 75 years old. ♦

RESULTS

Among 8,396 patients starting dialysis there were 3,173 patients older than 75. When using a Cox model, no association was found between age greater than 75 years and increased risk of peritonitis (hazard ratio [HR]: 0.97 [0.88 - 1.07]). Diabetes (HR: 1.14 [1.01 - 1.28] and continuous ambulatory PD (HR: 1.13 [1.04 - 1.23]) were significantly associated with a higher risk of peritoneal infection whereas nurse-assisted PD was associated with a lower risk of peritonitis (HR: 0.85 [0.78 - 0.94]. In the analysis restricted to the 3,840 self-care PD patients, there was no association between age older than 75 years and risk of peritonitis. ♦

CONCLUSION

The risk of peritonitis is not increased in elderly patients on PD in a country where assisted PD is available.

Results in Assisted Peritoneal Dialysis: A Ten-Year Experience

Background/Aims. Peritoneal dialysis is a successful renal replacement therapy (RRT) for old and dependent patients. We evaluated the clinical outcomes of an assisted peritoneal dialysis (aPD) program developed in a Portuguese center. Methods. Retrospective study based on 200 adult incident patients admitted during ten years to a PD program. We included all 17 patients who were under aPD and analysed various parameters, including complications with the technique, hospitalizations, and patient and technique survival. Results. The global peritonitis rate was lower in helped than in nonhelped patients: 0.4 versus 0.59 episodes/patient/year. The global hospitalization rate was higher in helped than in nonhelped patients: 0.67 versus 0.45 episodes/patient/year (p = NS). Technique survival in helped patients versus nonhelped patients was 92.3%, 92.3%, 83.1%, and 72.7% versus 91.9%, 81.7%, and 72.1%, and 68.3%, at 1, 2, 3, and 4 years, respectively (p = NS), and patient survival in helped patients versus nonhelped patients was 93.3%, 93.3%, 93.3%, and 74.7% versus 95.9% 93.7%, 89%, and 82% at 1, 2, 3, and 4 years, respectively (p = NS). Conclusions. aPD offers an opportune, reliable, and effective home care alternative for patients with no other RRT options.

Quality of life and emotional distress in patients and burden in caregivers: a comparison between assisted peritoneal dialysis and self-care peritoneal dialysis

PURPOSE

Assisted peritoneal dialysis (PD) involving caregivers allows more patients to get started on home-based dialysis with good clinical outcomes, but evidence on patient-reported and caregiver-reported outcomes is lacking. This study aimed to compare assisted PD versus self-care PD on quality of life (QoL) and psychosocial outcomes for patients and caregivers. The effect of PD modality [automated PD (APD); continuous ambulatory PD (CAPD)] in relation to self-care or assisted care was also examined.

METHODS

A cross-sectional sample of 231 PD patients [142 self-care (57 APD/85 CAPD) and 89 assisted care PD (45 APD/44 CAPD)], 72 caregivers of assisted PD patients and 39 family members of self-care PD patients completed the Kidney Disease Quality of Life Short Form (KDQOL-SF), World Health Organisation Quality of Life Instrument-brief and the Hospital Anxiety and Depression Scale. Caregivers and family members completed the Lay Care-Giving for Adults Receiving Dialysis questionnaire and Zarit Burden Interview.

RESULTS

Case-mix-adjusted comparisons indicated comparable QoL in all dimensions with the exception of physical SF-12 (p = .001) and the KDQOL effects of kidney disease in favour of self-care PD. Levels of anxiety (9.72 ± 4.90; 8.25 ± 5.22) and depression (8.63 ± 3.80; 6.35 ± 4.76) were equivalent in assisted PD and self-care PD, respectively. Assisted PD caregivers reported more task-orientated duties (p = .007), yet levels of perceived burden were equal to those reported by family members of self-care PD.

CONCLUSION

Our findings of mostly comparable patient and caregiver outcomes in assisted PD and self-care PD suggest that caregiver burden and QoL should not be a barrier to using assisted PD.

Dialysis Modality and Mortality in the Elderly: A Meta-Analysis

BACKGROUND AND OBJECTIVES

Identifying the appropriate choice between hemodialysis (HD) and peritoneal dialysis (PD) is an unresolved issue in elderly patients with ESRD, who are at high risk for death but have a low chance of receiving kidney transplantation.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Data on 13,065 incident dialysis Korean patients (age≥65 years) receiving HD (n=10,675) or PD (n=2390) were obtained from the Korean Health Insurance dataset. Multiple statistical approaches, including the multivariate Cox model, were used to compare mortality between Korean patients receiving PD and those receiving HD. Subsequently, meta-analysis of previous comparison studies (published since the year 2000; population-based studies) and the Korean dataset was performed.

RESULTS

During a mean duration of 1.8±1.3 years (maximum of 5 years), the Korean PD group had a higher mortality rate than the Korean HD group (hazard ratio [HR], 1.20 [95% confidence interval (95% CI), 1.13 to 1.28]; P<0.001 by multivariate Cox model). The discrepancy between the two modalities was greater in the presence of certain conditions, such as diabetes mellitus or longer dialysis duration. In the meta-analysis, 15 studies involving >631,421 elderly patients were reviewed. Compared with HD, the pooled HR with PD was 1.10 (95% CI, 1.01 to 1.20). When the meta-analysis was stratified by confounding factors, the survival benefit from HD was particularly strong in subgroups that had diabetes mellitus, had long dialysis duration (>1 year), or contained cohorts starting dialysis in the 1990s.

CONCLUSIONS

A meta-analysis that included results in Korean patients suggests a higher risk for death in elderly patients receiving PD than in those receiving HD.

Focus on peritoneal dialysis training: working to decrease peritonitis rates

Patient training has widely been considered to be one of the most critical factors for achieving optimal peritoneal dialysis clinical outcomes, including avoidance of peritonitis. However, research in this important area has been remarkably scant to date. This article will critically review the clinical evidence underpinning PD patient training and will specifically focus on four key areas: who should provide training and how, when and where should it be performed to obtain the best results. Evidence gaps and future research directions will also be discussed.

Evaluating the benefits of home-based peritoneal dialysis

Peritoneal dialysis (PD) is an effective renal replacement strategy for patients suffering from end-stage renal disease. PD offers patient survival comparable to or better than in-center hemodialysis while preserving residual kidney function, empowering patient autonomy, and reducing financial burden to payors. The majority of patients suffering from kidney failure are eligible for PD. In patients with cardiorenal syndrome and uncontrolled fluid status, PD is of particular benefit, decreasing hospitalization rates and duration. This review discusses the benefits of chronic PD, performed by the patient or a caregiver at home. Recognition of the benefits of PD is a cornerstone in stimulating the use of this treatment strategy.

Chronic kidney disease and support provided by home care services: a systematic review

BACKGROUND

Chronic diseases, such as chronic kidney disease (CKD), are growing in incidence and prevalence, in part due to an aging population. Support provided through home care services may be useful in attaining a more efficient and higher quality care for CKD patients.

METHODS

A systematic review was performed to identify studies examining home care interventions among adult CKD patients incorporating all outcomes. Studies examining home care services as an alternative to acute, post-acute or hospice care and those for long-term maintenance in patients' homes were included. Studies with only a home training intervention and those without an applied research component were excluded.

RESULTS

Seventeen studies (10 cohort, 4 non-comparative, 2 cross-sectional, 1 randomized) examined the support provided by home care services in 15,058 CKD patients. Fourteen studies included peritoneal dialysis (PD), two incorporated hemodialysis (HD) and one included both PD and HD patients in their treatment groups. Sixteen studies focused on the dialysis phase of care in their study samples and one study included information from both the dialysis and pre-dialysis phases of care. Study settings included nine single hospital/dialysis centers and three regional/metropolitan areas and five were at the national level. Studies primarily focused on nurse assisted home care patients and mostly examined PD related clinical outcomes. In PD studies with comparators, peritonitis risks and technique survival rates were similar across home care assisted patients and comparators. The risk of mortality, however, was higher for home care assisted PD patients. While most studies adjusted for age and comorbidities, information about multidimensional prognostic indices that take into account physical, psychological, cognitive, functional and social factors among CKD patients was not easily available.

CONCLUSIONS

Most studies focused on nurse assisted home care patients on dialysis. The majority were single site studies incorporating small patient populations. There are gaps in the literature regarding the utility of providing home care to CKD patients and the impact this has on healthcare resources.

Home visit program improves technique survival in peritoneal dialysis

BACKGROUND

Peritoneal dialysis (PD) is a home therapy, and technique survival is related to the adherence to PD prescription at home. The presence of a home visit program could improve PD outcomes. We evaluated its effects on clinical outcome during 1 year of follow-up.

METHODS

This was a case-control study. The case group included all 96 patients who performed PD in our center on January 1, 2013, and who attended a home visit program; the control group included all 92 patients who performed PD on January 1, 2008. The home visit program consisted of several additional visits to reinforce patients' confidence in PD management in their own environment. Outcomes were defined as technique failure, peritonitis episode, and hospitalization. Clinical and dialysis features were evaluated for each patient.

RESULTS

The case group was significantly older (p = 0.048), with a lower grade of autonomy (p = 0.033), but a better hemoglobin level (p = 0.02) than the control group. During the observational period, we had 11 episodes of technique failure. We found a significant reduction in the rate of technique failure in the case group (p = 0.004). Furthermore, survival analysis showed a significant extension of PD treatment in the patients supported by the home visit program (52 vs. 48.8 weeks, p = 0.018). We did not find any difference between the two groups in terms of peritonitis and hospitalization rate; however, trends toward a reduction of Gram-positive peritonitis rates as well as prevalence and duration of hospitalization related to PD problems were identified in the case group. The retrospective nature of the analysis was a limitation of this study.

CONCLUSION

The home visit program improves the survival of PD patients and could reduce the rate of Gram-positive peritonitis and hospitalization. Video Journal Club "Cappuccino with Claudio Ronco" at http://www.karger.com/?doi=365168.

[Assisted peritoneal dialysis: home-based renal replacement therapy for the elderly patient]

The number of elderly patients with end stage renal disease is constantly increasing. Conventional hämodiaylsis as the mainstay of renal replacement therapy is often poorly tolerated by frail eldery patients with multiple comorbidities. Although many of these patients would prefer a home based dialysis treatment, the number of elderly patients using peritoneal dialysis (PD) is still low. Impaired physical and cognitive function often generates insurmountable barriers for self care peritoneal dialysis. Assisted peritoneal dialysis can overcome many of these barriers and give elderly patients the ability of a renal replacement therapy in their own homes respecting their needs.

A Brazilian experience in assisted automated peritoneal dialysis: a reliable and effective home care approach

INTRODUCTION

Automated assisted peritoneal dialysis (AAPD) has been shown to be successful as renal replacement therapy for elderly and physically incapable end-stage renal disease (ESRD) patients. In early 2003, a pioneer AAPD program was initiated at GAMEN Renal Clinic in Rio de Janeiro, Brazil. ♢

OBJECTIVE

We evaluated the results of an AAPD program offered as an option to elderly ESRD patients with physical or cognitive debilities or as last resort to patients with vascular access failure or hemodynamic instability during hemodialysis. ♢

METHODS

A cohort of 30 consecutive patients started AAPD from January 2003 to March 2008 and was followed to July 2009. Demographics, clinical and laboratory parameters, causes of death, and patient and technique survival were analyzed. ♢

RESULTS

Median age of the patients was 72 years (range: 47 - 93 years), with 60% being older than 65. The Davies score was greater than 2 in 73% of patients, and the Karnofsky index was less than 70 in 40%. The overall peritonitis rate was 1 episode in 37 patient-months. The total duration of AAPD ranged from 3 to 72 months. Patient survival was 80% at 12 months, 60% at 24 months, and 23.3% at 48 months. The most common cause of death was cardiovascular problems (70%). ♢

CONCLUSIONS

In this clinical observational study, AAPD fulfilled its expected role, offering an opportune, reliable, and effective homecare alternative for ESRD patients with no other renal replacement therapy options.

Patients' preferences regarding choice of end-stage renal disease treatment options

BACKGROUND

Dialysis registries have reported a low take-up of home treatment. The aim of our study was to report patients' preferred treatment options for end-stage renal disease (ESRD) after information delivery, patients' characteristics by treatment preference, and the reasons for differences between treatment preference and the treatment delivered.

METHODS

A prospective cohort study on patients seen in our nephrology department between January 2009 and June 2011 included all patients with chronic kidney disease (GFR <20 ml/min/1.73 m(2)) and incident dialysis patients who received an information program about ESRD treatment options.

RESULTS

228 patients received information delivery and either expressed a preference for a given renal replacement therapy (peritoneal dialysis, PD: 42%; hemodialysis, HD: 33%), remained undecided (20%) or expressed reluctance to undergo renal replacement therapy (5%). Multivariate analysis revealed that compared to HD preference, patients preferring PD were older (OR 1.02, 95% CI 1.0-1.04), had a lower BMI (OR 0.9, 95% CI 0.87-0.98) and were more likely to have been informed before rather than after starting dialysis (OR 3.4, 95% CI 1.5-7.4); home treatment was the main reason given for preferring PD. Undecided patients were mainly women and the majority were eventually treated by HD. Reluctant patients were the oldest (OR 1.12, 95% CI 1.02-1.22) and were rarely treated by dialysis. Only 24% of patients informed before and 8% of patients informed after starting dialysis were ultimately treated with PD. Reasons for a mismatch between dialysis modality preference and treatment delivered were equally distributed between medical and nonmedical.

CONCLUSION

Patients should be systematically informed before starting dialysis, patients' preferences should be taken into account before organizing dialysis and all treatment modalities should be available in all centers.

Is assisted peritoneal dialysis associated with technique survival when competing events are considered?

BACKGROUND AND OBJECTIVES

This study assessed whether assisted peritoneal dialysis (PD) was associated with a lower risk for technique failure using methods developed for survival analysis in the presence of competing risks.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This retrospective cohort study, based on data from the French Language Peritoneal Dialysis Registry, analyzed 9822 incident patients starting PD between January 2002 and December 2010. The observation period ended on June 1, 2011. Time to transfer to hemodialysis was compared between patients with assisted PD and those undergoing self-care PD.

RESULTS

There were 5286 patients undergoing assisted PD; 4230 of these were assisted by a community nurse and 1056 by family. Assisted PD patients were older and had a higher Charlson comorbidity index than self-care PD patients. There were 7594 events: 3495 deaths, 2464 transfers to hemodialysis, 1489 renal transplantations, and 146 renal function recoveries. According to a Cox model, assistance and center size were associated with a lower risk for technique failure, whereas hemodialysis before PD, early peritonitis, and transplantation failure were associated with a higher risk for transfer to hemodialysis. A Fine and Gray regression model showed that assisted PD was associated with a lower risk for transfer to hemodialysis.

CONCLUSIONS

Compared with patients undergoing self-care PD, those with assisted PD had a lower risk for transfer to hemodialysis, a higher risk for death, and a lower risk for transplantation.

Systematic barriers to the effective delivery of home dialysis in the United States: a report from the Public Policy/Advocacy Committee of the North American Chapter of the International Society for Peritoneal Dialysis

Home dialysis, currently underused in the United States compared with other industrialized countries, likely will benefit from the newly implemented US prospective payment system. Not only is home dialysis less expensive from the standpoint of pure dialysis costs, but overall health system costs may be decreased by more subtle benefits, such as reduced transportation. However, many systematic barriers exist to the successful delivery of home dialysis. We organized these barriers into the categories of educational barriers (patient and providers), governmental/regulatory barriers (state and federal), and barriers specifically related to the philosophies and business practices of dialysis providers (eg, staffing, pharmacies, supplies, space, continuous quality improvement practices, and independence). All stakeholders share the goal of delivering home dialysis therapies in the most cost- and clinically effective and least problematic manner. Identification and recognition of such barriers is the first step. In addition, we have suggested action plans to stimulate the kidney community to find even better solutions so that collectively we may overcome these barriers.

Experiences with assisted peritoneal dialysis in China

OBJECTIVE

About half the patients on peritoneal dialysis (PD) in China need to be assisted by family members or home assistants. We explored whether these patients have a higher risk for peritonitis and death compared with self-care PD patients.

METHODS

We prospectively followed 313 incident PD patients until death or censoring. This cohort was divided into assisted and self-care PD groups according to the independence of bag exchange. Data on baseline demographics, Charlson comorbidity index, biochemistry, and residual renal function were recorded during the first 3 - 6 months. The outcome variables were first episode of peritonitis and all-cause mortality.

RESULTS

Of the 313 patients in this cohort study, 122 needed assistance in performing bag exchanges (86 from a family member, 36 from a home assistant); the remaining 191 patients did not need assistance. During a follow-up period averaging 44.5 months, 122 patients developed a first episode of peritonitis, and 135 patients died. Compared with patients having a family assistant, those with a home assistant had similar peritonitis-free and survival times, but a higher risk of mortality after adjustments for variables such as age, sex, Charlson comorbidity score, hemoglobin, serum albumin, and residual renal function. Furthermore, compared with self-care patients, assisted patients overall had a similar peritonitis-free time, but a higher risk of mortality, even after adjusting for covariates.

CONCLUSIONS

Based on our single-center experience in China, we conclude that assisted PD is a good option for patients with poor self-care ability. This result provides evidence for recruiting patients who need assistance to PD programs in China.

Peritoneal dialysis in an ageing population: a 10-year experience

BACKGROUND

Chronic kidney disease (CKD) is becoming increasingly prevalent and there are increasing numbers of older patients with advanced CKD. Peritoneal dialysis (PD) is a potential treatment. This study aims to compare PD outcomes in age-defined populations in the largest PD centre in the Republic of Ireland over 10 years.

METHODS

We retrospectively identified all adult patients, over the age of 50 years, who commenced PD as their first modality of renal replacement therapy (RRT) between 1 January 1998 and 31 December 2008 at our institution. Primary outcome was patient survival; secondary outcomes were technique failure, peritonitis-free survival, transplantation and hospitalisations.

RESULTS

One hundred and forty-eight patients with a mean age of 63 years were included. Twenty-two patients were on assisted PD, the majority of whom were aged 70 years or over (P = 0.001). There were no differences in patient survival or technique failure by age group, Charlson Co-Morbidity Index (CCI), modified-CCI or adjusted CCI. Renal transplantation occurred predominantly in younger patients (P = 0.001) with lower m-CCI (P = 0.001) and a-CCI (P = 0.002) who performed PD independently (P = 0.004). Older patients required longer hospital stays to initiate PD (P = 0.004). Assisted PD was not associated with an increase in early complications or technique failure but death rates were higher (P = 0.002).

CONCLUSION

This study shows PD to be an acceptable modality of renal replacement therapy in elderly patients, with no observed differences in survival, technique survival or complication rates. Co-morbidities appear to play a stronger role in predicting survival than age alone. Assisted PD is a viable option in those unable to undergo PD independently.

Peritoneal dialysis in polycystic kidney disease patients. Report from the French peritoneal dialysis registry (RDPLF)

BACKGROUND

It is commonly believed that polycystic kidney disease (PKD) patients on peritoneal dialysis (PD) are over-exposed to technique failure and peritonitis compared with other patients. This study was carried out to assess whether PKD is associated with technique failure and to evaluate the outcome of PKD patients on PD.

METHODS

This was a retrospective cohort study based on the data of the French Language Peritoneal Dialysis Registry. We analysed 4162 incident non-diabetic patients who started PD between January 2002 and December 2007. The end of the observation period was 31 December 2008.

RESULTS

Among 4162 patients, there were 344 PKD patients and 3818 patients who had another underlying nephropathy. PKD patients were younger, had a lower Charlson comorbidity index, were more frequently treated by automated PD and were less frequently assisted than other patients. For the PKD patients, the main reason for PD cessation was renal transplantation. In the multivariate analysis, comorbidities and centre size were associated with technique survival, and no association between PKD and technique failure was observed. There was no statistically significant association between PKD and peritonitis or between PKD and enteric peritonitis. On multivariate analysis, patient survival was associated with PKD and with patient age, comorbidities and the modality of assistance. Centre size was not associated with patient survival.

CONCLUSION

PD is a suitable method for at least a subgroup of PKD patients reaching end-stage renal disease in a country where renal transplantation is available.