Outcome measures for technique survival reported in peritoneal dialysis: A systematic review

Staying home when peritoneal dialysis ends: the integrated home dialysis approach

PURPOSE OF REVIEW

Home dialysis has been promoted for several years for patients starting dialysis. Although incident use of peritoneal dialysis (PD) and home hemodialysis (HHD) is increasing in several regions, patients on home dialysis remain at high risk of transfer to facility-hemodialysis (HD). The integrated home dialysis model, where patient start dialysis on PD and eventually transition to HHD when PD cannot be optimally continued has gain interest from dialysis stakeholders.

RECENT FINDINGS

Transfers from PD to HHD are infrequently used among patients ending PD, representing between 2% and 6% of transfers to HD in registry studies. Nonetheless, this approach is associated with several clinical benefits as well as favorable cost-effectiveness.

SUMMARY

In this review, we will present data pertaining to home dialysis and the integrated home dialysis model, with broad discussion of the implementation challenges, including identifying patients who could most benefit from this approach, timely planning of the transitions and challenges relating to unexpected PD endings.

Effects of initial peritoneal dialysis prescription on clinical outcomes in Japanese peritoneal dialysis patients: a cohort study

Effects of the initial peritoneal dialysis (PD) prescription on clinical outcomes are unknown in Japan. We conducted a cohort study using data from Peritoneal Dialysis Outcomes and Practice Patterns Study. The patients were divided into two groups by the volume of the initial PD prescription (≤ 4 L/day or > 4 L/day). Cause-specific Cox proportional hazards survival models were used to model the association between different PD prescriptions and the clinical outcomes. The outcomes included transfer to HD, mortality, the composite of mortality and transfer to HD, peritonitis, hospitalization, and the patient-reported outcomes (PROs). Of the 342 patients, 98 were prescribed ≤ 4 L/day, and 244 were prescribed > 4 L/day. Patients prescribed ≤ 4 L/day were older with a lower percentage being male, had more cardiovascular and cerebrovascular disease but lower diabetes prevalence, were more likely to be receiving CAPD, used more assisted PD, and had lower BMI and mean serum creatinine levels. There were no significant differences between groups in terms of transfer to HD, mortality, transfer to HD or mortality, hospitalization, incidence of peritonitis, and PROs. Patients with initial PD prescriptions of ≤ 4 L/day compared to > 4 L/day had similar clinical outcomes. This practice may provide health economic benefits in Japan.

Risk factors and outcomes in patients who switched from peritoneal dialysis to physician-oriented or patient-oriented kidney replacement therapy

BACKGROUND

We aimed to compare the cardiovascular events and mortality in patients who underwent either physician-oriented or patient-oriented kidney replacement therapy (KRT) conversion due to discontinuation of peritoneal dialysis (PD).

METHODS

Patients with end-stage kidney disease who were receiving PD and required a switch to an alternative KRT were included. They were divided into physician-oriented group or patient-oriented group based on the decision-making process. Logistic regression analysis was used to explore the influencing factors related to KRT conversion in PD patients. The association of physician-oriented or patient-oriented KRT conversion with outcomes after the conversion was assessed by using Cox proportional hazards models.

RESULTS

A total of 257 PD patients were included in the study. The median age at catheterization was 35 years. 69.6% of the participants were male. The median duration of PD was 20 months. 162 participants had patient-oriented KRT conversion, while 95 had physician-oriented KRT conversion. Younger patients, those with higher education levels, higher income, and no diabetes were more likely to have patient-oriented KRT conversion. Over a median follow-up of 39 months, 40 patients experienced cardiovascular events and 16 patients died. Physician-oriented KRT conversion increased nearly 3.8-fold and 4.0-fold risk of cardiovascular events and death, respectively. After adjusting for confounders, physician-oriented KRT conversion remained about a 3-fold risk of cardiovascular events.

CONCLUSION

Compared to patient-oriented KRT conversion, PD patients who underwent physician-oriented conversion had higher risks of cardiovascular events and all-cause mortality. Factors included age at catheterization, education level, annual household income, and history of diabetes mellitus.

Impact of compliance with salt management guidelines before dialysis introduction on peritoneal dialysis technique survival: The importance of pre-dialysis care and education

INTRODUCTION

Peritoneal dialysis (PD) is a mode of therapy in which the patients themselves actively participate in the care of their own disease. We examined a possible association of salt reduction before starting dialysis with PD technique survival.

METHODS

This retrospective cohort study included 42 patients who started PD between April 2014 and March 2018. Participants were allocated to two groups based on their estimated daily salt intake before the initiation of dialysis: patients with an estimated daily salt intake <6 g/day were allocated to the appropriate salt intake group (AS group), while the rest were assigned to the high salt intake group (HS group).

RESULTS

During a median follow-up of 47 months, PD technique survival, defined by death or transition to hemodialysis, was significantly lower in the HS group compared to the AS group.

CONCLUSION

Successful salt reduction before dialysis introduction is associated with better PD technique survival.

Establishing a peritoneal dialysis technique survival core outcome measure: A standardised outcomes in nephrology-peritoneal dialysis consensus workshop report

BACKGROUND

Technique survival, also reported with negative connotations as technique failure or transfer from peritoneal dialysis to haemodialysis, has been identified by patients, caregivers and health professionals as a critically important outcome to be reported in all trials. However, there is wide variation in how peritoneal dialysis technique survival is defined, measured and reported, leading to difficulty in comparing or consolidating results.

METHODS

We conducted an online international consensus workshop to establish a core outcome measure of technique survival. Discussions were analysed thematically.

RESULTS

Fifty-five participants including 14 patients and caregivers from 13 countries took part in facilitated breakout discussions using video-conferencing. The following themes were identified: capturing important aspects of the outcome (requiring a core event to define the outcome, distinguishing temporary from permanent events, recognising heterogeneous experiences of transfers), adopting appropriate neutral nomenclature (conveying with clarity, avoiding negative connotations), and ensuring feasibility and applicability (capturing data relevant to clinical and research settings, ease of adoption). The suggested definitions for the core outcome measure were 'the event of a transfer to haemodialysis', or 'discontinuation of peritoneal dialysis'. Applying the principles described within the workshop, defining the outcome measure as a 'transfer to haemodialysis' was preferable.

CONCLUSIONS

It is proposed that the core outcome of technique survival is redefined as 'transfer to haemodialysis' and that its components are standardised using simple, neutral terminology Components considered important by stakeholders included recording the reasons for transfer from peritoneal dialysis, and focussing on permanent events whilst ensuring the outcome remains easy to implement.

Development and validation of prediction model for technique failure in peritoneal dialysis patients: An observational study

AIM

This study aimed to establish a prediction model in peritoneal dialysis patients to estimate the risk of technique failure and guide clinical practice.

METHODS

Clinical and laboratory data of 424 adult peritoneal dialysis patients were retrospectively collected. The risk prediction models were built using univariate Cox regression, best subsets approach and LASSO Cox regression. Final nomogram was constructed based on the best model selected by the area under the curve.

RESULTS

After comparing three models, the nomogram was built using the LASSO Cox regression model. This model included variables consisting of hypertension and peritonitis, serum creatinine, low-density lipoprotein, fibrinogen and thrombin time, and low red blood cell count, serum albumin, triglyceride and prothrombin activity. The predictive model constructed performed well using receiver operating characteristic curve and area under the curve value, C-index and calibration curve.

CONCLUSION

This study developed and verified a new prediction instrument for the risk of technique failure among peritoneal dialysis patients.

A multi-institutional, observational study of outcomes after catheter placement for peritoneal dialysis in Japan

BACKGROUND

This multi-institutional, observational study examined whether the outcomes after peritoneal dialysis (PD) catheter placement in Japan meet the audit criteria of the International Society for Peritoneal Dialysis (ISPD) guideline and identified factors affecting technique survival and perioperative complications.

METHODS

Adult patients who underwent first PD catheter placement for end-stage kidney disease between April 2019 and March 2021 were followed until PD withdrawal, kidney transplantation, transfer to other facilities, death, 1 year after PD start or March 2022, whichever came first. Primary outcomes were time to catheter patency failure and technique failure, and perioperative infectious complications within 30 days of catheter placement. Secondary outcomes were perioperative complications. Appropriate statistical analyses were performed to identify factors associated with the outcomes of interest.

RESULTS

Of the total 409 patients, 8 who underwent the embedded catheter technique did not have externalised catheters. Of the 401 remaining patients, catheter patency failure occurred in 25 (6.2%). Technical failure at 12 months after PD catheter placement calculated from cumulative incidence function was 15.3%. On Cox proportional hazards model analysis, serum albumin (hazard ratio (HR) 0.44; 95% confidence interval (CI) 0.27-0.70) and straight type catheter (HR 2.14; 95% CI 1.24-3.69) were the independent risk factors for technique failure. On logistic regression analysis, diabetes mellitus was the only independent risk factor for perioperative infectious complications (odds ratio 2.70, 95% CI 1.30-5.58). The occurrence rate of perioperative complications generally met the audit criteria of the ISPD guidelines.

CONCLUSION

PD catheter placement in Japan was proven to be safe and appropriate.

Why are we Not Getting More Patients onto Peritoneal Dialysis? Observations From the United States with Global Implications

Peritoneal dialysis (PD) offers lifestyle advantages over in-center hemodialysis (HD) and is less costly. However, in the United States, less than 12% of end-stage kidney disease (ESKD) patients are maintained on this modality. In this brief review, we discuss some of the factors underlying the low prevalence of PD. These include inadequate patient education, a shortage of sufficiently well-trained medical and nursing personnel, absence of infrastructure to support urgent start PD, and lack of support for assisted PD, among other factors. Understanding and addressing these various issues may help increase the prevalence of PD in the United States and globally.

Range and consistency of gastrointestinal outcomes reported in peritoneal dialysis trials: A systematic review

BACKGROUND

Gastrointestinal (GI) health is considered vital to the success of peritoneal dialysis (PD) and is critically important to patients, caregivers and clinicians. However, the multiplicity of GI outcome measures in trials undermines the ability to evaluate the frequency, impact and treatment of GI symptoms in patients receiving PD. Therefore, this study aimed to assess the range and consistency of GI outcomes reported in contemporary PD trials.

STUDY DESIGN

Systematic review.

SETTING AND POPULATION

Individuals with kidney failure requiring PD.

SELECTION CRITERIA

All randomised controlled trials involving patients on PD, identified from the PUBMED, EMBASE and COCHRANE Central Registry of controlled Trials (CENTRAL) database, from January 2010 to July 2022.

INTERVENTIONS

Any PD-related intervention.

OUTCOMES

The frequency and characteristics of GI outcome measures were analysed and classified.

RESULTS

Of the 324 eligible PD trials, GI outcomes were only reported in 61 (19%) trials, mostly as patient-reported outcomes (45 trials; 74%). The most frequently reported outcomes were nausea in 27 (43%), diarrhoea in 26 (43%), vomiting in 22 (36%), constipation in 21 (34%) and abdominal pain in 19 (31%) of trials. PD peritonitis was the primary non-GI outcome reported in 24 (40%) trials, followed by death in 13 (21%) trials) and exit-site infection in 9 (15%) trials). Across all trials, 172 GI outcome measures were extracted and grouped into 29 different outcomes. Nausea and diarrhoea contributed to 16% and 15% of GI outcomes, respectively, while vomiting, constipation and abdominal pain contributed to 13%, 12% and 12%, respectively. Most (90%) GI outcomes were patient-reported adverse effects with no defined metrics. Faecal microbiome was reported as the primary study outcome in 3 (100%) trials using the subjective global assessment score, GI symptom rating scale and faecal microbiological and biochemical analysis. Two trials reported nausea as a primary study outcome using symptom assessment score (SAS) and kidney disease quality of life-short-form-36. One trial each reported anorexia and abdominal pain as the primary study outcome using SAS. Bowel habits, constipation and stool type were also reported as the primary study outcome in one trial each using the Bristol stool form scale. GI bleeding was reported as the secondary outcome in three (37%) out of eight trials reporting it.

LIMITATIONS

Restricted sampling frame to focus on contemporary trials.

CONCLUSIONS

Despite the clinical importance of GI outcomes among patients on PD, they are reported in only 19% of PD trials, using inconsistent metrics, often as patient-reported adverse events. Efforts to standardise GI outcome reporting are critical to optimising comparability, reliability and value of trial evidence to improve outcomes for patients receiving PD.

Epidemiology of peritoneal dialysis outcomes

Peritoneal dialysis (PD) is an important home-based treatment for kidney failure and accounts for 11% of all dialysis and 9% of all kidney replacement therapy globally. Although PD is available in 81% of countries, this provision ranges from 96% in high-income countries to 32% in low-income countries. Compared with haemodialysis, PD has numerous potential advantages, including a simpler technique, greater feasibility of use in remote communities, generally lower cost, lesser need for trained staff, fewer management challenges during natural disasters, possibly better survival in the first few years, greater ability to travel, fewer dietary restrictions, better preservation of residual kidney function, greater treatment satisfaction, better quality of life, better outcomes following subsequent kidney transplantation, delayed need for vascular access (especially in small children), reduced need for erythropoiesis-stimulating agents, and lower risk of blood-borne virus infections and of SARS-CoV-2 infection. PD outcomes have been improving over time but with great variability, driven by individual and system-level inequities and by centre effects; this variation is exacerbated by a lack of standardized outcome definitions. Potential strategies for outcome improvement include enhanced standardization, monitoring and reporting of PD outcomes, and the implementation of continuous quality improvement programmes and of PD-specific interventions, such as incremental PD, the use of biocompatible PD solutions and remote PD monitoring.

The use of peritoneal dialysis (PD) can be advantageous compared with haemodialysis treatment, although several barriers limit its broad implementation. This review examines the epidemiology of peritoneal dialysis (PD) outcomes, including clinical, patient-reported and surrogate PD outcomes.

Peritoneal dialysis (PD) has distinct advantages compared with haemodialysis, including the convenience of home treatment, improved quality of life, technical simplicity, lesser need for trained staff, greater cost-effectiveness in most countries, improved equity of access to dialysis in resource-limited settings, and improved survival, particularly in the first few years of initiating therapy.

Important barriers can hamper PD utilization in low-income settings, including the high costs of PD fluids (owing to the inability to manufacture them locally and the exorbitant costs of their import), limited workforce availability and a practice culture that limits optimal PD use, often leading to suboptimal outcomes.

PD outcomes are highly variable around the world owing in part to the use of variable outcome definitions, a heterogeneous practice culture, the lack of standardized monitoring and reporting of quality indicators, and kidney failure care gaps (including health care workforce shortages, inadequate health care financing, suboptimal governance and a lack of good health care information systems).

Key outcomes include not only clinical outcomes (typically defined as medical outcomes based on clinician assessment or diagnosis) — for example, PD-related infections, technique survival, mechanical complications, hospitalizations and PD-related mortality — but also patient-reported outcomes. These outcomes are directly reported by patients and focus on how they function or feel, typically in relation to quality of life or symptoms; patient-reported outcomes are used less frequently than clinical outcomes in day-to-day routine care.

Imaging and leaks in peritoneal dialysis

Dialysate leaks are non-rare mechanical but dreaded complications in peritoneal dialysis (PD). They usually occur at the beginning of PD, with various clinical events depending on their location. Use of imaging tests such as computed tomography (CT) peritoneography, or magnetic resonance imaging (MRI) peritoneography, or scintigraphic peritoneography, can confirm the diagnosis and guide surgical intervention if needed. These simple, non-invasive, and accessible tests can be done in collaboration between the radiological et peritoneal teams. Depending on the leakage site, PD can be pursued with small volumes with a cycler. In other cases, it must be interrupted and the patient transferred to hemodialysis, in order to permit the peritoneal cavity to regain its integrity by cicatrization or with surgical intervention. Imaging can help to make sure peritoneal cavity has regained its integrity after this period of transition. Early leaks can be avoided by delaying PD start with by 14 days. Intraperitoneal pressure does not seem to contribute significantly. Prevention of PD leaks essentially depends on individual risk factors such as obesity or anterior abdominal surgeries. This article reviews the characteristics of dialysate leaks in PD and the imagery tests to limit transfer to hemodialysis.

Outcome measures for technique survival reported in peritoneal dialysis: A systematic review

BACKGROUND

Peritoneal dialysis (PD) technique survival is an important outcome for patients, caregivers and health professionals, however, the definition and measures used for technique survival vary. We aimed to assess the scope and consistency of definitions and measures used for technique survival in studies of patients receiving PD.

METHOD

MEDLINE, EMBASE and CENTRAL databases were searched for randomised controlled studies (RCTs) conducted in patients receiving PD reporting technique survival as an outcome between database inception and December 2019. The definition and measures used were extracted and independently assessed by two reviewers.

RESULTS

We included 25 RCTs with a total of 3645 participants (41-371 per trial) and follow up ranging from 6 weeks to 4 years. Terminology used included 'technique survival' (10 studies), 'transfer to haemodialysis (HD)' (8 studies) and 'technique failure' (7 studies) with 17 different definitions. In seven studies, it was unclear whether the definition included transfer to HD, death or transplantation and eight studies reported 'transfer to HD' without further definition regarding duration or other events. Of those remaining, five studies included death in their definition of a technique event, whereas death was censored in the other five. The duration of HD necessary to qualify as an event was reported in only four (16%) studies. Of the 14 studies reporting causes of an event, all used a different list of causes.

CONCLUSION

There is substantial heterogeneity in how PD technique survival is defined and measured, likely contributing to considerable variability in reported rates. Standardised measures for reporting technique survival in PD studies are required to improve comparability.