Dialysis modality and outcomes in kidney transplant recipients

Insights Into Peritoneal Dialysis Outcomes: An Approach Using Competing Risks Analysis

Peritoneal dialysis (PD) outcomes analysis presents challenges due to heterogeneous outcomes. Our study aims to evaluate mortality, transition to hemodialysis (HD), and kidney transplant (KT) rates and investigate potential baseline patient characteristics influencing these outcomes. We conducted an observational retrospective registry-based single-center cohort study involving 722 incident adult PD patients admitted between 1985 and 2022. Follow-up duration extended from PD initiation to the first occurrence of death (n = 143), transfer to HD (n = 313), or KT (n = 202). Utilizing competitive risks analysis, we calculated cumulative incidence (CI) functions and applied a Fine and Gray model to baseline variables to understand their impact. The majority of patients were female (n = 401; 55.54%), with an average age of 49.64 ± 15.80 years. Transfer to HD had the highest probability (CI of 0.38 at 60 months), followed by KT (CI of 0.27 at 60 months) and death (CI of 0.19 at 60 months). Diabetes correlated solely with death (HR 1.71 (0.18); p = 0.004). PD-first was associated with a lower risk of HD transfer (HR 0.76 (0.13); p = 0.036) and positively influenced KT (HR 1.73 (0.16); p < 0.01). Vascular access as the reason for PD selection was associated with death (HR 2.16 (0.19); p < 0.001). The main risk for PD patients is transitioning to HD, unaffected by baseline patient characteristics. PD-first option positively influences KT access, and mortality rates remain low and unaffected by this option, ensuring the safety of the technique. Vascular access-related PD initiations correlate with increased mortality, potentially due to comorbidities.

Peritoneal dialysis and kidney transplantation: Your questions answered

Peritoneal dialysis (PD) and kidney transplantation are important therapeutic options in patients with advanced kidney disease. This article delineates the relationship between PD and kidney transplantation in several key domains, including: (1) Comparative merits and limitations of PD versus center-based hemodialysis prior to kidney transplantation, (2) Patient outcomes after kidney transplantation in individuals receiving PD prior to kidney transplantation, (3) Perioperative management strategies of patients receiving PD at the time of kidney transplantation, and (4) The relative advantages and clinical outcomes of PD use following kidney allograft failure compared to other modalities. This article aims to provide comprehensive guidance for optimizing care across the PD-kidney transplant transitions continuum.

Impact of Pretransplant Dialysis Modality on Posttransplant Outcomes: A Single-Center Experience

OBJECTIVES

It remains unclear whether posttransplant outcomes differ according to the pretransplant dialysis modality (peritoneal dialysis vs hemodialysis). Our aim was to assess posttransplant outcomes in patients with different predialysis modalities.

MATERIALS AND METHODS

Two thousand two hundred fifty-eight kidney recipients following up in Hamed Alessa Organ transplant center in Kuwait were included and divided into two groups according to pre-transplant dialysis modality: Group 1: those who received hemodialysis (HD) and group 2: those with peritoneal dialysis (PD). Demographics, pretransplant and posttransplant comorbidities, and patient and graft outcomes were studied.

RESULTS

There were 1956 patients on hemodialysis, and 302 patients were on peritoneal dialysis. Most were male patients (1456 vs 802 female patients), with comparable mean age (P = .34). Chronic glomerulonephritis and diabetic nephropathy represented the most common original kidney disease before transplant (27.6% and 21.4%, respectively), with higher prevalence of glomerulonephritis in group 1 and diabetic nephropathy in group 2 (P = .001). The 2 groups were comparable with regard to immunosuppression (induction and maintenance) (P > .05). Posttransplant diabetes and hypertension were significantly higher in the hemodialysis group (P = .004 and P = 003, respectively). There was no significant difference between the 2 groups with regard to the graft outcome (P = .86). However, patient survival was significantly higher in the hemodialysis group (81.2% vs 64.4%).

CONCLUSIONS

Compared with peritoneal dialysis, pretransplant hemodialysis is associated with better posttransplant patient survival despite no difference in the graft outcome. Diabetes-related complications could be attributed to such outcomes.

The Relationship Between C-Reactive Protein (CRP) Concentrations and Erythropoietin Resistance, Hospital Admission Rate, Control of Mineral Metabolism, and Comorbidity in Hemodialysis Patients

Background End-stage kidney disease patients undergoing hemodialysis are prone to develop inflammation detected by high serum C-reactive protein (CRP) levels. This study highlights the association between CRP and the erythropoietin resistance index, hospital admission rate, control of mineral metabolism, and comorbidities in a tertiary hospital and two dialysis centers in Saudi Arabia. Objectives The objective of the study is to assess the relationship between CRP levels and hemoglobin level, hospital admission rate, mineral metabolism, and comorbidity in hemodialysis patients. Materials and methods This was a cross-sectional study conducted at King Abdulaziz Medical City Dialysis Center and the South and North Dialysis Centers of King Abdullah Dialysis Program in Riyadh. All hemodialysis adult patients who have been on dialysis for over six months were included. Patients with acute illnesses and pediatric patients were excluded. The association between CRP and other variables was reported using the Pearson correlation test. The calculated sample size was 218 by using the Raosoft website; however, the final number we analyzed was 209 after exclusion. Results The prevalence of a high level of CRP was more common among patients with diabetes mellitus (p=0.008) and those who were using antihypertensives (p=0.044) while the prevalence of a high level of CRP was less common among underweight patients (p=0.031) and hepatitis C virus (HCV)-positive patients (p=<0.001). The mean value of Kt/V was significantly lower among patients with a high level of CRP (p=0.009). HCV negative was the only independent significant risk factor associated with high CRP concentration (p=0.006). Conclusions In conclusion, there was an association between CRP levels with BMI, diabetics, the use of antihypertensive medications, and negative or undetectable HCV test results with the latter being the only independent significant factor. These data suggest that patients meeting these characteristics are in an inflammatory state and more prone to develop complications; thus, implementing CPR testing in this population might be useful. Other reviews showing causations are needed to further elucidate.

Association Between Pretransplant Dialysis Modality and Kidney Transplant Outcomes: A Systematic Review and Meta-analysis

IMPORTANCE

The benefits and disadvantages of different pretransplant dialysis modalities and their posttransplant outcomes remain unclear in contemporary kidney transplant care.

OBJECTIVE

To summarize the available evidence of the association of different pretransplant dialysis modalities, including hemodialysis and peritoneal dialysis (PD), with posttransplant outcomes.

DATA SOURCES

MEDLINE, Embase, PubMed, Cochrane Library, Scopus, CINAHL, and gray literature were searched from inception to March 18, 2022 (updated to April 1, 2022), for relevant studies and with no language restrictions.

STUDY SELECTION

Randomized clinical trials and nonrandomized observational (case-control and cohort) studies that investigated the association between pretransplant dialysis modality and posttransplant outcomes regardless of age or donor sources (living or deceased) were abstracted independently by 2 reviewers.

DATA EXTRACTION AND SYNTHESIS

Following Preferred Reporting Items for Systematic Reviews and Meta-analyses and Meta-analysis of Observational Studies in Epidemiology reporting guidelines, 2 reviewers independently extracted relevant information using a standardized approach. Random-effects meta-analysis was used to estimate pooled adjusted hazard ratio (HR) or odds ratio and 95% CI.

MAIN OUTCOMES AND MEASURES

Primary outcomes included all-cause mortality, overall graft failure, death-censored graft failure, and delayed graft function. Secondary outcomes included acute rejection, graft vessel thrombosis, oliguria, de novo heart failure, and new-onset diabetes after transplant.

RESULTS

The study analyzed 26 nonrandomized studies (1 case-control and 25 cohort), including 269 715 patients (mean recipient age range, 14.5-67.0 years; reported proportions of female individuals, 29.4%-66.9%) whose outcomes associated with pretransplant hemodialysis vs pretransplant PD were compared. No significant difference, with very low certainty of evidence, was observed between pretransplant PD and all-cause mortality (13 studies; n = 221 815; HR, 0.92 [95% CI, 0.84-1.01]; P = .08) as well as death-censored graft failure (5 studies; n = 96 439; HR, 0.98 [95% CI, 0.85-1.14]; P = .81). However, pretransplant PD was associated with a lower risk for overall graft failure (10 studies; n = 209 287; HR, 0.96 [95% CI, 0.92-0.99]; P = .02; very low certainty of evidence) and delayed graft function (6 studies; n = 47 118; odds ratio, 0.73 [95% CI, 0.70-0.76]; P < .001; low certainty of evidence). Secondary outcomes were inconclusive due to few studies with available data.

CONCLUSIONS AND RELEVANCE

Results of the study suggest that pretransplant PD is a preferred dialysis modality option during the transition to kidney transplant. Future studies are warranted to address shared decision-making between health care professionals, patients, and caregivers as well as patient preferences.

The Role of Peritoneal Dialysis in Different Phases of Kidney Transplantation

The utilization of peritoneal dialysis (PD) has been increasing in the past decade owing to various government initiatives and recognition of benefits such as better preservation of residual renal function, quality of life, and lower cost. The Advancing American Kidney Health initiative aims to increase the utilization of home therapies such as PD and kidney transplantation to treat end stage kidney disease (ESKD). A natural consequence of this development is that more patients will receive PD, and many will eventually undergo kidney transplantation. Therefore, it is important to understand the effect of pretransplant PD on posttransplant outcomes such as delayed graft function (DGF), rejection, thrombosis, graft, and patient survival. Furthermore, some of these patients may develop DGF, which raises the question of the utility of PD during DGF and its risks. Although transplant is the best renal replacement therapy option, it is not everlasting, and many transplant recipients must go on dialysis after allograft failure. Can PD be a good option for these patients? This is another critical question. Furthermore, a significant proportion of nonrenal solid organ transplant recipients develop ESKD. Is PD feasible in this group? In this review, we try to address all of these questions in the light of available evidence.

Impact of the Type of Dialysis on Time to Transplantation: Is It Just a Matter of Immunity?

Background: Renal transplantation represents the therapeutic gold standard in patients with end stage renal disease (ESRD). Still the role of pre-transplant dialysis in affecting time to transplantation has yet to be determined. We wanted to verify whether the type of renal replacement therapy (hemodialysis vs. peritoneal dialysis) affects time to transplantation and to identify clinical features related to the longer time to transplantation. Methods: We performed a retrospective single-center observational study on patients who had received a transplant in the Bologna Transplant Unit from 1991 to 2019, described through the analysis of digital transplant list documents for sex, age, body mass index (BMI), blood group, comorbidities, underlying disease, serology, type of dialysis, time to transplantation, Panel Reactive Antibodies (PRA) max, number of preformed anti Human Leukocyte Antigens (HLA) antibodies. A p-value < 0.05 was considered statistically significant. Results: In the 1619 patients analyzed, we observed a significant difference in time to transplant, PRA max and Preformed Antibodies Number between patients who received Hemodialysis (HD) and Peritoneal dialysis (PD). Then we performed a multiple regression analysis with all the considered factors in order to identify features that support these differences. The clinical variables that independently and directly correlate with longer time to transplantation are PRA max (p < 0.0001), Antibodies number (p < 0.0001) and HD (p < 0.0001); though AB blood group (p < 0.0001), age (p < 0.003) and PD (p < 0.0001) inversely correlate with time to transplantation. Conclusions: In our work, PD population received renal transplants in a shorter period of time compared to HD and turned out to be less immunized. Considering immunization, the type of dialysis impacts both on PRA max and on anti HLA antibodies.

Peritoneal Dialysis for Potential Kidney Transplant Recipients: Pride or Prejudice?

Kidney transplantation (KT) is recognized as the gold-standard of treatment for patients with end-stage renal disease. Additionally, it has been demonstrated that receiving a pre-emptive KT ensures the best recipient and graft survivals. However, due to an overwhelming discrepancy between the organs available and the patients on the transplant waiting list, the vast majority of transplant candidates require prolonged periods of dialysis before being transplanted. For many years, peritoneal dialysis (PD) and hemodialysis (HD) have been considered competitive renal replacement therapies (RRT). This dualistic vision has recently been questioned by evidence suggesting that an individualized and flexible approach may be more appropriate. In fact, tailored and cleverly planned changes between different RRT modalities, according to the patient's needs and characteristics, are often needed in order to achieve the best results. While home HD is still under scrutiny in this particular setting, current data seems to favor the use of PD over in-center HD in patients awaiting a KT. In this specific population, the demonstrated advantages of PD are superior quality of life, longer preservation of residual renal function, lower incidence of delayed graft function, better recipient survival, and reduced cost.

Changes in Treatment of Patients with Incident ESKD during the Novel Coronavirus Disease 2019 Pandemic

BACKGROUND

The COVID-19 pandemic caused major disruptions to care for patients with advanced CKD.

METHODS

We investigated the incidence of documented ESKD, ESKD treatment modalities, changes in eGFR at dialysis initiation, and use of incident central venous catheters (CVCs) by epidemiologic week during the first half of 2020 compared with 2017-2019 historical trends, using Centers for Medicare and Medicaid Services data. We used Poisson and logistic regression for analyses of incidence and binary outcomes, respectively.

RESULTS

Incidence of documented ESKD dropped dramatically in 2020 compared with the expected incidence, particularly during epidemiologic weeks 15-18 (April, incidence rate ratio [IRR], 0.75; 95% CI, 0.73 to 0.78). The decrease was most pronounced for individuals aged ≥75 years (IRR, 0.69; 95% CI, 0.66 to 0.73). Pre-emptive kidney transplantation decreased markedly during weeks 15-18 (IRR, 0.56; 95% CI, 0.46 to 0.67). Mean eGFR at dialysis initiation decreased by 0.33 ml/min per 1.73 m2 in weeks 19-22; non-Hispanic Black patients exhibited the largest decrease, at 0.61 ml/min per 1.73 m2. The odds of initiating dialysis with eGFR <10 ml/min per 1.73 m2 were highest during weeks 19-22 (May, OR, 1.14; 95% CI, 1.05 to 1.17), corresponding to an absolute increase of 2.9%. The odds of initiating peritoneal dialysis (versus hemodialysis) were 24% higher (OR, 1.24; 95% CI, 1.14 to 1.34) in weeks 11-14, an absolute increase of 2.3%. Initiation with a CVC increased by 3.3% (OR, 1.30; 95% CI, 1.20 to 1.41).

CONCLUSIONS

During the first wave of the COVID-19 pandemic, the number of patients starting treatment for ESKD fell to a level not observed since 2011. Changes in documented ESKD incidence and other aspects of ESKD-related care may reflect differential access to care early in the pandemic.

Optimizing Decellularization Strategies for the Efficient Production of Whole Rat Kidney Scaffolds

BACKGROUND

Renal dysfunction remains a global issue, with chronic kidney disease being the 18th most leading cause of death, worldwide. The increased demands in kidney transplants, led the scientific society to seek alternative strategies, utilizing mostly the tissue engineering approaches. Unlike to perfusion decellularization of kidneys, we proposed alternative decellularization strategies to obtain acellular kidney scaffolds. The aim of this study was the evaluation of two different decellularization approaches for producing kidney bioscaffolds.

METHODS

Rat kidneys from Wistar rats, were submitted to decellularization, followed two different strategies. The decellularization solutions used in both approaches were the same and involved the use of 3-[(3-cholamidopropyl) dimethylammonio]-1-propanesulfonate and sodium dodecyl sulfate buffers for 12 h each, followed by incubation in a serum medium. Both approaches involved 3 decellularization cycles. Histological analysis, biochemical and DNA quantification were performed. Cytotoxicity assay and repopulation of acellular kidneys were also applied.

RESULTS

Histological, biochemical and DNA quantification confirmed that the 2nd approach had the best outcome regarding the kidney composition and cell elimination. Acellular kidneys from both approaches were successfully recellularized.

CONCLUSION

Based on the above data, the production of kidney scaffolds with the proposed cost- effective decellularization approaches, was efficient.

The probability of receiving a kidney transplantation in end-stage kidney disease patients who are treated with haemodiafiltration or haemodialysis: a pooled individual participant data from four randomised controlled trials

Background

Due to a critical shortage of available kidney grafts, most patients with Stage 5 Chronic Kidney Disease (CKD5) require bridging dialysis support. It remains unclear whether treatment by different dialysis modalities changes the selection and/or preparation of a potential transplant candidate. Therefore, we assessed whether the likelihood of receiving kidney transplant (both living or deceased kidney donors) differs between haemodialysis (HD) and online haemodiafiltration (HDF) in patients with CKD5D.

Methods

Individual participant data from four randomised controlled trials comparing online HDF with HD were used. Information on kidney transplant was obtained during follow-up. The likelihood of receiving a kidney transplant was compared between HD and HDF, and evaluated across different subgroups: age, sex, diabetes, history of cardiovascular disease, albumin, dialysis vintage, fistula, and level of convection volume standardized to body surface area. Hazard ratios (HRs), with corresponding 95% confidence intervals (95% CI), comparing the effect of online HDF versus HD on the likelihood of receiving a kidney transplant, were estimated using Cox proportional hazards models with a random effect for study.

Results

After a median follow-up of 2.5 years (Q1 to Q3: 1.9–3.0), 331 of the 1620 (20.4%) patients with CKD5D received a kidney transplant. This concerned 22% (n = 179) of patients who were treated with online HDF compared with 19% (n = 152) of patients who were treated with HD. No differences in the likelihood of undergoing a kidney transplant were found between the two dialysis modalities in both the crude analyse (HR: 1.07, 95% CI: 0.86–1.33) and adjusted analysis for age, sex, diabetes, cardiovascular history, albumin, and creatinine (HR: 1.15, 95%-CI: 0.92–1.44). There was no evidence for a differential effect across subgroups based on patient- and disease-characteristics nor in different categories of convection volumes.

Conclusions

Treatment with HD and HDF does not affect the selection and/or preparation of CKD5D patients for kidney transplant given that the likelihood of receiving a kidney transplant does not differ between the dialysis modalities. These finding persisted across a variety of subgroups differing in patient and disease characteristics and is not affected by the level of convection volume delivered during HDF treatment sessions.

Practice patterns of dialysis access and outcomes in patients wait-listed early for kidney transplantation

BACKGROUND

Early kidney transplantation (KT) is the best option for patients with end-stage kidney disease, but little is known about dialysis access strategy in this context. We studied practice patterns of dialysis access and how they relate with outcomes in adults wait-listed early for KT according to the intended donor source.

METHODS

This study from the REIN registry (2002-2014) included 9331 incident dialysis patients (age 18-69) wait-listed for KT before or by 6 months after starting dialysis: 8342 candidates for deceased-donor KT and 989 for living-donor KT. Subdistribution hazard ratios (SHR) of KT and death associated with hemodialysis by catheter or peritoneal dialysis compared with arteriovenous (AV) access were estimated with Fine and Gray models.

RESULTS

Living-donor candidates used pretransplant peritoneal dialysis at rates similar to deceased-donor KT candidates, but had significantly more frequent catheter than AV access for hemodialysis (adjusted OR 1.25; 95%CI 1.09-1.43). Over a median follow-up of 43 (IQR: 23-67) months, 6063 patients received transplants and 305 died before KT. Median duration of pretransplant dialysis was 15 (7-27) months for deceased-donor recipients and 9 (5-15) for living-donor recipients. Catheter use in deceased-donor candidates was associated with a lower SHR for KT (0.88, 95%CI 0.82-0.94) and a higher SHR for death (1.53, 95%CI 1.14-2.04). Only five deaths occurred in living-donor candidates, three of them with catheter use.

CONCLUSIONS

Pretransplant dialysis duration may be quite long even when planned with a living donor. Advantages from protecting these patients from AV fistula creation must be carefully evaluated against catheter-related risks.

Risk factors and etiology of repeat infection in kidney transplant recipients

Kidney transplantation (KT) is the best therapy available for patients with end-stage renal disease, but postoperative infections are a significant cause of mortality.In this retrospective study the frequency, risk factors, causative pathogens, and clinical manifestations of infection in KT recipients from Beijing Chao-Yang Hospital, Capital Medical University were investigated. Ninety-seven KT recipients who were hospitalized with infection between January 2010 and December 2016 were included. Clinical characteristics, surgery details, laboratory results, and etiology were compared in patients who developed single infection and patients who developed repeated infection (2 or more) after KT.A total of 161 infections were adequately documented in a total of 97 patients, of which 57 patients (58.8%) had 1 infection, 24 (24.7%) had 2, 11 (11.3%) had 3; 3 (3.1%) had 4, and 2 (2.1%) had 5 or more. The most common infection site was the urinary tract (90 infections; 56%), both overall and in the repeated infection group. The most frequently isolated pathogen was Pseudomonas aeruginosa. In the repeated infection patients, in most cases of P. aeruginosa infection (54%) it was cultured from urine. For first infections, a time between KT and infection of ≤ 21 days (area under receiver operating characteristic curve [AUC] 0.636) and a tacrolimus level ≥ 8 ng/mL (AUC 0.663) independently predicted repeat infection. The combination of these two predictive factors yielded an AUC of 0.716, which did not differ statistically significantly from either predictor alone.With regard to first infections after KT, a time between KT and infection of ≤ 21 days, and a tacrolimus level ≥ 8 ng/mL each independently predicted repeated infection in KT recipients.

Effect of Pretransplant Dialysis Modality on Outcomes After Simultaneous Pancreas-Kidney Transplantation

Background

Pretransplant dialysis modality may affect outcome after simultaneous pancreas-kidney transplantation (SPKT), and it has been suspected that peritoneal dialysis (PD) is associated with more postoperative complications compared to hemodialysis (HD). The aim of this study was to evaluate whether pretransplant dialysis modality affects the risk for postoperative complications in SPKT recipients.

Material/Methods

This was a retrospective longitudinal cohort study of all patients undergoing SPKT from 2010 to 2017, during which 99 simultaneous pancreas-kidney transplantations were performed. Three pre-emptive transplantations were excluded. Patient groups receiving PD (n=59) or HD (n=37) were similar regarding baseline characteristics. All complications occurring during the first 3 months after transplantation, as well as patient and graft survival, were analyzed.

Results

There were no significant differences in postoperative complications between groups, with similar rates of intra-abdominal infections (8% in HD vs. 10% in PD), pancreatitis (16% in HD vs. 17% in PD), gastrointestinal bleedings (22% in HD vs. 10% in PD), and relaparotomies (27% in HD vs. 24% in PD). None of the patients had venous graft thrombosis. Past peritonitis was not associated with increased risk for postoperative complications in PD patients. Patient and graft survival were similar between PD and HD groups.

Conclusions

Peritoneal dialysis is not a risk factor for postoperative complications after SPKT.

Association of Cold Ischemia Time With Acute Renal Transplant Rejection

BACKGROUND

Kidney transplantation holds much promise as a treatment of choice for patients with end-stage kidney disease. The impact of cold ischemia time (CIT) on acute renal transplant rejection (ARTR) remains to be fully studied in a large cohort of renal transplant patients.

METHODS

From the Organ Procurement and Transplantation Network database, we analyzed 63 798 deceased donor renal transplants performed between 2000 and 2010. We assessed the association between CIT and ARTR. We also evaluated the association between recipient age and ARTR.

RESULTS

Six thousand eight hundred two (11%) patients were clinically diagnosed with ARTR. Longer CIT was associated with an increased risk of ARTR. After multivariable adjustment, compared with recipients with CIT < 12 hours, the relative risk of ARTR was 1.13 (95% confidence interval, 1.04-1.23) in recipients with CIT ≥ 24 hours. The association of CIT and ARTR was more pronounced in patients undergoing retransplantation: compared with recipients with CIT less than 12 hours, the relative risk of ARTR was 1.66 (95% confidence interval, 1.01-2.73) in recipients with CIT of 24 hours or longer. Additionally, older age was associated with a decreased risk of ARTR. Compared with recipients aged 18 to 29 years, the relative risk of ARTR was 0.50 (95% confidence interval, 0.45-0.57) in recipients 60 years or older. Longer CIT was also associated with increased risk of death-censored graft loss. Compared with recipients with CIT less than 12 hours, the hazard ratio of death-censored graft loss was 1.22 (95% confidence interval, 1.14-1.30) in recipients with CIT of 24 hours or longer.

CONCLUSIONS

Prolonged CIT is associated with an increased risk of ARTR and death-censored graft loss. Older age was associated with a lower risk of ARTR.

Choice of dialysis modality prior to kidney transplantation: Does it matter?

The population of patients with end stage renal disease (ESRD) is increasing, lengthening waiting lists for kidney transplantation. Majority of the patients are not able to receive a kidney transplant in timely manner even though it is well established that patient survival and quality of life after kidney transplantation is far better when compared to being on dialysis. A large number of patients who desire a kidney transplant ultimately end up needing some form of dialysis therapy. Most of incident ESRD patients choose hemodialysis (HD) over peritoneal dialysis (PD) as the modality of choice in the United States, even though studies have favored PD as a better choice of pre-transplant dialysis modality than HD. PD is largely underutilized in the United States due to variety of reasons. As a part of the decision making process, patients are often educated how the choice regarding modality of dialysis would fit into their life but it is not clear and not usually discussed, how it can affect eventual kidney transplantation in the future. In this article we would like to discuss ESRD demographics and outcomes, modality of dialysis and kidney transplant related events. We have summarized the data comparing PD and HD as the modality of dialysis and its impact on allograft and recipient outcomes after kidney transplantation.

Effects of pretransplant peritoneal vs hemodialysis modality on outcome of first kidney transplantation from donors after cardiac death

Background

The effect of pretransplant peritoneal dialysis (PD) or hemodialysis (HD) modality on outcomes of kidney transplantation (KT) for end-stage renal disease (ESRD) is debatable. We evaluated the outcomes these modalities in KT from donor after cardiac death (DCD).

Methods

A cohort of 251 patients on HD, PD or pre-emptive who underwent first KT from DCD between January 2014 and December 2016 were prospectively analyzed to compare for outcomes on recovery of renal function, complications as well as patient and graft survival. The patients were followed till August 2017. Data on 104 HD and 98 PD were available for final comparative outcome analysis, 5 pre-emptive were analyzed as the control group.

Results

Both HD and PD group patients were well matched for demographic and baseline characteristics. The follow-up period was 12.5 (3.0, 22.0) months in HD and 12.0 (6.0, 20.0) months in PD patients. Post-transplant renal functions between the two groups showed no differences. Among PD patients, 16 (16.3%) suffered delayed graft function, versus 19 (18.3%) in HD, with no statistical differences (p = 0.715). Complications of acute rejection, infections were comparable between the groups. The patient survival, graft survival and death-censored graft survival were similar for HD and PD after adjusting for other multiple risk factors.

Conclusions

Our results indicate that outcome of first KT from DCD is not affected by pretransplant dialysis modality of PD or HD in aspects of recovery of renal function, complications as well as patient and graft survival.

Impact of the pretransplant dialysis modality on kidney transplantation outcomes: a nationwide cohort study

OBJECTIVE

Most patients with uraemia must undergo chronic dialysis while awaiting kidney transplantation; however, the role of the pretransplant dialysis modality on the outcomes of kidney transplantation remains obscure. The objective of this study was to clarify the associations between the pretransplant dialysis modality, namely haemodialysis (HD) or peritoneal dialysis (PD), and the development of post-transplant de novo diseases, allograft failure and all-cause mortality for kidney-transplant recipients.

DESIGN

Retrospective nationwide cohort study.

SETTING

Data retrieved from the Taiwan National Health Insurance Research Database.

PARTICIPANTS

The National Health Insurance database was explored for patients who received kidney transplantation in Taiwan during 1998-2011 and underwent dialysis >90 days before transplantation.

OUTCOME MEASURES

The pretransplant characteristics, complications during kidney transplantation and post-transplant outcomes were statistically analysed and compared between the HD and PD groups. Cox regression analysis was used to evaluate the HR of the dialysis modality on graft failure and all-cause mortality. The primary outcomes were long-term post-transplant death-censored allograft failure and all-cause mortality started after 90 days of kidney transplantation until the end of follow-up. The secondary outcomes were events during kidney transplantation and post-transplant de novo diseases adjusted by propensity score in log-binomial model.

RESULTS

There were 1812 patients included in our cohort, among which 1209 (66.7%) and 603 (33.3%) recipients received pretransplant HD and PD, respectively. Recipients with chronic HD were generally older and male, had higher risks of developing post-transplant de novo ischaemic heart disease, tuberculosis and hepatitis C after adjustment. Pretransplant HD contributed to higher graft failure in the multivariate analysis (HR 1.38, p<0.05) after adjustment for the recipient age, sex, duration of dialysis and pretransplant diseases. There was no significant between-group difference in overall survival.

CONCLUSIONS

Pretransplant HD contributed to higher risks of death-censored allograft failure after kidney transplantation when compared with PD.

Paired Analysis of Outcomes After Kidney Transplantation in Peritoneal and Hemodialysis Patients

BACKGROUND

The impact of dialysis modality before kidney transplantation (hemodialysis or peritoneal dialysis) on outcomes is not clear. In this study we retrospectively analyzed the impact of dialysis modality on posttransplant follow-up.

METHODS

To minimize donor bias, a paired kidney analysis was applied. One hundred thirty-three pairs of peritoneal dialysis (PD) and hemodialysis (HD) patients were transplanted at our center between 1994 and 2016. Those who received kidneys from the same donor were included in the study. HD patients were significantly older (44 vs 48 years), but the Charlson Comorbidity Index was similar (3.12 vs 3.46) in both groups. The groups did not differ significantly with respect to immunosuppressive protocols and number of mismatches (2.96 vs 2.95).

RESULTS

One-year patient (98% vs 96%) and graft (90% vs 93%) survival was similar in the PD and HD patient groups. The Kaplan-Meier curves of the patients and graft survival did not differ significantly. Delayed graft function (DGF) and acute rejection (AR) occurred significantly more often in the HD recipients. Graft vessel thrombosis resulting in graft loss occurred in 9 PD (6.7%) and 4 HD (3%) patients (P > .05). Serum creatinine concentration and estimated glomerular filtration rate (using the Modification of Diet in Renal Disease guidelines) showed no difference at 1 month, 1 year, and at final visit. On multivariate analysis, factors significantly associated with graft loss were graft vessel thrombosis, DGF, and graft function 1 month after transplantation. On univariate analysis, age, coronary heart disease, and graft loss were associated with death. Among these factors, only coronary heart disease (model 1) and graft loss were significant predictors of death on multivariate analysis.

CONCLUSION

The long-term outcome for renal transplantation is similar in patients with PD and HD. These groups differ in some aspects, however, such as susceptibility to vascular thrombosis in PD patients, and to DGF and AR in HD patients.

Risk of peritoneal dialysis catheter-associated peritonitis following kidney transplant

OBJECTIVE

Peritoneal dialysis (PD) patients have equivalent or slightly better kidney transplant outcomes when compared to hemodialysis (HD) patients. However, given the risk for postoperative infection, we sought to determine the risk factors for PD catheter-associated infections for patients who do not have the PD catheter removed at the time of engraftment.

METHODS

Demographic and outcomes data were collected from 313 sequential PD patients who underwent kidney transplant from 2000 to 2015. Risk factors for postoperative peritonitis were analyzed using logistical regression.

RESULTS

Of 329 patients with PD catheters at transplant, 16 PD catheters were removed at engraftment. Of the remaining 313 patients, 8.9% suffered post-transplant peritonitis. On univariate analysis, patients with peritonitis were significantly more likely to have used the PD catheter or HD within 6 weeks after transplant. Multivariate analysis had similar findings, with increased risk for those using the PD catheter after transplant, with a trend for those who underwent HD only within 6 weeks of transplant.

CONCLUSION

These results suggest that delayed graft function requiring any type of dialysis is associated with increased post-transplant peritonitis risk.

Predictive Score for Posttransplantation Outcomes

BACKGROUND

Most current scoring tools to predict allograft and patient survival upon kidney transplantion are based on variables collected posttransplantation. We developed a novel score to predict posttransplant outcomes using pretransplant information including routine laboratory data available before or at the time of transplantation.

METHODS

Linking the 5-year patient data of a large dialysis organization to the Scientific Registry of Transplant Recipients, we identified 15 125 hemodialysis patients who underwent first deceased transplantion. Prediction models were developed using Cox models for (a) mortality, (b) allograft loss (death censored), and (c) combined death or transplant failure. The cohort was randomly divided into a two thirds set (Nd = 10 083) for model development and a one third set (Nv = 5042) for validation. Model predictive discrimination was assessed using the index of concordance, or C statistic, which accounts for censoring in time-to-event models (a-c). We used the bootstrap method to assess model overfitting and calibration using the development dataset.

RESULTS

Patients were 50 ± 13 years of age and included 39% women, 15% African Americans, and 36% persons with diabetes. For prediction of posttransplant mortality and graft loss, 10 predictors were used (recipients' age, cause and length of end-stage renal disease, hemoglobin, albumin, selected comorbidities, race and type of insurance as well as donor age, diabetes status, extended criterion donor kidney, and number of HLA mismatches). The new model (www.TransplantScore.com) showed the overall best discrimination (C-statistics, 0.70; 95% confidence interval [95% CI], 0.67-0.73 for mortality; 0.63; 95% CI, 0.60-0.66 for graft failure; 0.63; 95% CI, 0.61-0.66 for combined outcome).

CONCLUSIONS

The new prediction tool, using data available before the time of transplantation, predicts relevant clinical outcomes and may perform better to predict patients' graft survival than currently used tools.

Effect of center practices on the choice of the first dialysis modality for children and young adults

BACKGROUND

Peritoneal dialysis (PD) remains the modality of choice in children, but there is no clear evidence to support a better outcome in children treated with PD. We aimed to assess factors that have an impact on the choice of dialysis modality in children and young adults in France and sought to determine the roles of medical factors and center practices.

METHODS

We included all patients aged <20 years at the start of renal replacement therapy (RRT), recorded in the French RRT Registry between 2002 and 2013. Hierarchical logistic regression models were used to study the association between the patient/center characteristics and the probability of receiving PD as the first dialysis modality.

RESULTS

We included 806 patients starting RRT in 177 centers, 23 of which were specialized pediatric centers. Six hundred and one patients (74.6 %) started with hemodialysis (HD), whereas 205 (25.4 %) started with PD. A greater probability of PD was found in younger children, whereas starting the treatment in an emergency setting was associated with a low use of PD. We found a significant variability among centers that accounted for 43 % of the total variability. The probability of PD was higher in adult centers and was proportional to the rate of PD in the center.

CONCLUSIONS

Center practices are a major factor in the choice of dialysis modality. This raises concerns about patient and family choices and to what extent doctors may influence the final decision. Further pediatric studies focusing on children's and parents' wishes are needed to provide care as close as possible to patients' and families' expectations.

Association of Pre-Transplant Dialysis Modality and Post-Transplant Outcomes: A Meta-Analysis

♦ BACKGROUND: It remains unclear whether post-transplant outcomes differ according to the pre-transplant dialysis modality (peritoneal dialysis [PD] versus hemodialysis [HD]). We performed a meta-analysis of studies that assessed either post-transplant mortality, graft survival, or delayed graft function (DGF) in both PD and HD patients. ♦ METHODS: Two independent authors searched English-language literature from January 1, 1980, through August 31, 2014, national conference proceedings, and reference lists. We used combinations of terms related to dialysis (hemodialysis, peritoneal dialysis, or renal replacement therapy), kidney transplant, and outcomes. Studies were included if they measured any of the 3 post-transplant study outcomes in both pre-transplant HD and PD. ♦ RESULTS: A total of 16 studies were included in the final analysis. Of these, 6 studies reported adjusted hazard ratio for mortality, pooled adjusted risk ratio: 0.89 (95% confidence interval [CI] 0.82 - 0.97) in favor of PD (p = 0.006). The same 6 studies reported adjusted hazard ratio for graft survival, pooled adjusted risk ratio: 0.97 (95% CI 0.92 - 1.01, p = 0.16). A total of 13 studies reported unadjusted DGF. Pooled odds ratio: 0.5 (95% CI 0.41 - 0.63) in favor of PD (p < 0.005). Significant heterogeneity observed for all outcomes: I2 = 72.7%, I2 = 59.9%, and I2 = 66.8%, respectively. ♦ CONCLUSIONS: Based on these results, pre-transplant PD is associated with better post-transplant survival than HD. Pre-transplant PD was also associated with decreased risk for DGF compared with HD, although these results were unadjusted. There was no significant difference in graft survival between pre-transplant HD and PD. These results suggest that PD may be the preferred dialysis modality for patients expected to receive a transplant.

Pre-transplant dialysis modality does not influence short- or long-term outcome in kidney transplant recipients: analysis of paired kidneys from the same deceased donor

Previous studies have reported contradictory results regarding the effect of pre-transplant dialysis modality on the outcomes after kidney transplantation (KT). To minimize the confounding effect of donor-related variables, we performed a donor-matched retrospective comparison of 160 patients that received only one modality of pre-transplant dialysis (peritoneal dialysis [PD] and hemodialysis [HD] in 80 patients each) and that subsequently underwent KT at our center between January 1990 and December 2007. Cox regression models were used to evaluate the association between pre-transplant dialysis modality and primary study outcomes (death-censored graft survival and patient survival). To control for imbalances in recipient-related baseline characteristics, we performed additional adjustments for the propensity score (PS) for receiving pre-transplant PD (versus HD). There were no significant differences according to pre-transplant dialysis modality in death-censored graft survival (PS-adjusted hazard ratio [aHR]: 0.65; 95% confidence interval [95% CI]: 0.25-1.68) or patient survival (aHR: 0.58; 95% CI: 0.13-2.68). There were no differences in 10-year graft function or in the incidence of post-transplant complications either, except for a higher risk of lymphocele in patients undergoing PD (odds ratio: 4.31; 95% CI: 1.15-16.21). In conclusion, pre-transplant dialysis modality in KT recipients does not impact short- or long-term graft outcomes or patient survival.

Overcoming the Underutilisation of Peritoneal Dialysis

Peritoneal dialysis is troubled with declining utilisation as a form of renal replacement therapy in developed countries. We review key aspects of therapy evidenced to have a potential to increase its utilisation. The best evidence to repopulate PD programmes is provided for the positive impact of timely referral and systematic and motivational predialysis education: average odds ratio for instituting peritoneal dialysis versus haemodialysis was 2.6 across several retrospective studies on the impact of predialysis education. Utilisation of PD for unplanned acute dialysis starts facilitated by implantation of peritoneal catheters by interventional nephrologists may diminish the vast predominance of haemodialysis done by central venous catheters for unplanned dialysis start. Assisted peritoneal dialysis can improve accessibility of home based dialysis to elderly, frail, and dependant patients, whose quality of life on replacement therapy may benefit most from dialysis performed at home. Peritoneal dialysis providers should perform close monitoring, preventing measures, and timely prophylactic therapy in patients judged to be prone to EPS development. Each peritoneal dialysis programme should regularly monitor, report, and act on key quality indicators to manifest its ability of constant quality improvement and elevate the confidence of interested patients and financing bodies in the programme.

Pancreas-Kidney transplantation: Impact of dialysis modality on the outcome

It remains controversial whether dialysis modality prior to SPKT (simultaneous pancreas-kidney transplantation) affects the outcome. We analyzed outcomes in type 1 diabetic patients undergoing SPKT, comparing peritoneal dialysis (PD) and hemodialysis (HD) groups: 119 had been on HD; 39 on PD. They were comparable except regarding dialysis time, higher in HD patients (30 ± 23 vs. 21 ± 15 months, P = 0.003). Thrombosis-driven relaparotomy was more frequent in PD patients (12.8% vs. 1.7%, P = 0.014). Pancreas loss due to infection was higher in PD patients (12.8% vs. 3.4%, P = 0.042). Thrombosis-related kidney loss was more frequent in PD patients (5.1%, vs. 0% in HD patients, P = 0.058). Thirteen deaths occurred, more within the PD group (17.9% vs. 5%; P = 0.011), being infection the leading cause (13.5%, vs. 1.7% in HD patients, P = 0.010). Patient survival was inferior in PD patients. Besides PD, cardiovascular disease and graft failure were independent predictors of patient death. In conclusion, PD patients more frequently complicated with intra-abominal infection leading to pancreatic loss and with renal thrombosis, with adverse impact on survival. As a PD first strategy in end-stage renal disease patients is generally associated with good outcomes, these gloomier results after SPKT urge for careful adjustment of infection and thrombosis prophylactic protocols in PD patients.

Global scientific vision with local vigilance: renal transplantation in developing countries

CONTEXT

Renal Transplantation is the most effective treatment for patients with end-stage renal disease, which is fortunately available in the developing countries, even for poor people. Nonetheless, the way forward should be the implementation of advanced science of transplantation, allograft monitoring abilities, knowledge about the epidemiology of renal disease in any specific region, awareness about the influence of ethenic and genetic factors immunosuppressant bioavailability, and post-transplant complications all strongly affecting the patients and allograft survival.

EVIDENCE ACQUISITIONS

In this process we searched mainly in PubMed, Web of Science and Google Scholar data bases for key words of renal allograft monitoring, post-transplant infections, renal/kidney transplantation and Iran. We followed the cross articles to follow our main idea to find a connection between modern advancement in renal allograft monitoring and our practice in developing countries. Another focus was on the special infectious and non-infection complication that do exist in specific region and need specific considerations.

RESULTS

Implementation of modern techniques of immune monitoring, allograft function, awareness about the specific infectious and non-infectious disease in each region improves the quality of renal transplantation.

CONCLUSIONS

We need to combine the advance scientific vision with local vigilance to achieve the best outcome in renal allograft recipients.

Association of pre-transplant blood pressure with post-transplant outcomes

BACKGROUND

Previous studies have indicated U-shaped associations between blood pressure (BP) and mortality in dialysis patients. We hypothesized that a similar association exists between pre-transplant BP and post-transplant outcomes in dialysis patients who undergo successful kidney transplantation.

METHODS

Data from the Scientific Registry of Transplant Recipients were linked to the five-yr cohort of a large dialysis organization in the United States. We identified all dialysis patients who received a kidney transplant during this period. Unadjusted and multivariate adjusted predictors of transplant outcomes were examined.

RESULTS

A total of 13 881 patients included in our study were 47 ± 14 yr old and included 42% women. There was no association between pre-transplant systolic BP and post-transplant mortality, although a decreased risk trend was observed in those with low post-dialysis systolic BP. Compared to patients with pre-dialysis diastolic BP 70 to <80 mmHg, patients with pre-dialysis diastolic BP <50 mmHg experienced lower risk of post-transplant death (hazard ratios [HR]: 0.74, 95% CI: 0.55-0.99). However, compared to patients with post-dialysis diastolic BP 70 to <80 mmHg, patients with post-dialysis diastolic BP ≥100 mmHg experienced higher risk of death (HR: 3.50, 95% CI: 1.57-7.84). In addition, very low (<50 mmHg for diastolic BP and <110 mmHg for systolic BP) pre-transplant BP was associated with lower risk of graft loss.

CONCLUSIONS

Low post-dialysis systolic BP and low pre-dialysis diastolic BP are associated with lower post-transplant risk of death, whereas very high post-dialysis diastolic BP is associated with higher mortality in kidney transplant recipients. BP variations in dialysis patients prior to kidney transplantation may have a bearing on post-transplant outcome, which warrants additional studies.

Peritoneal dialysis versus hemodialysis in patients with delayed graft function

Delayed graft function (DGF) in kidney transplantation affects adverse outcomes. It remains unclear whether the post-transplant dialysis modality alters perioperative or long-term graft outcomes. We performed a retrospective observational quality initiative at two Canadian renal transplant centers, in which DGF occurred in the recipient, necessitating one of peritoneal dialysis (PD) or hemodialysis (HD). There was no difference in baseline factors between patients with post-transplant PD (n = 14) or HD (n = 63). The use of PD was associated with an increased risk of wound infection/leakage (PD 5/14 vs. HD 6/63, p = 0.024), shorter length of hospitalization (13.7 vs. 18.7 d, p = 0.009) and time requiring dialysis post-operatively (6.5 vs 11.0 d, p = 0.043). There were no differences in readmission to hospital within 6 months (4/14 vs. 23/63, p = 0.759), graft loss (0/14 vs. 2/63, p = 1.000) or acute rejection episodes (1/14 vs. 4/63, p = 1.000) at one yr, and GFR did not differ between the PD or HD groups at 30 d (35.7 vs. 33.8 mL/min/m(2), p = 0.731), six months (46.9 vs. 45.5 mL/min/m(2), p = 0.835) or one yr (46.6 vs. 44.5 mL/min/m(2), p = 0.746). Further research is needed to determine which transplant patients are most appropriate to undergo PD catheter removal at the time of transplantation.

Pretransplant peritoneal dialysis relative to hemodialysis improves long-term survival of kidney transplant patients: a single-center observational study

BACKGROUND

Kidney transplantation is the best option for the treatment of end-stage renal disease in terms of survival and quality of life. These results can be influenced by the pretransplant dialysis modality. The aim of this study was to evaluate whether the pretransplantation dialysis modality influences patient and allograft survival beyond 10 years and examine the potential risk factors associated with the outcomes.

METHODS

We conducted an observational, retrospective, single-center clinical study that included 236 patients [118 undergoing peritoneal dialysis (PD) and 118 undergoing hemodialysis (HD)] who proceeded to transplantation during the period December 1990-2002. Donor and recipient data were collected from our hospital's clinical registries. The follow-up period extended to the patient's death, the loss of the allograft, or loss to follow-up. The end date of the study was set at March 2012.

RESULTS

In the multivariate analysis, the long-term patient survival rate was higher for the PD group than for the HD group [HR = 2.62 (1.01-6.8); p = 0.04]; however, the allograft survival rate was not significantly different between the two groups [HR = 0.68 (0.41-1.10); p = 0.12].

CONCLUSION

Pretransplantation dialysis modality is associated with long-term patient survival, with outcomes favoring peritoneal dialysis over hemodialysis. However, the pretransplant dialysis modality does not influence long-term graft loss risk.

The role of peritoneal dialysis in modern renal replacement therapy

Most patients starting dialysis can choose between peritoneal dialysis and haemodialysis. There is little evidence proving that one form of dialysis is better than the other; although there may be an early advantage to peritoneal dialysis (PD) in young patients with residual function this effect is short-lived. Technique failure develops after years on PD so dialysis modality will often change during a long dialysis career. Quality of life studies, which must be interpreted carefully, indicate that patients require information about the impact of dialysis on their lifestyle as well as health-related outcomes so that they can choose the most suitable dialysis modality. Increasing numbers of frail elderly patients are starting dialysis; support in the home by nursing staff may facilitate the use of PD in this group. In the UK guidelines prioritise the patient's choice of dialysis modality (where feasible) based on good quality predialysis education. Cost of treatment is generally lower on PD, which is particularly recommended for patients with residual renal function and few comorbidities.

Association of pre-kidney transplant markers of mineral and bone disorder with post-transplant outcomes

BACKGROUND AND OBJECTIVES

Mineral and bone disorders (MBDs) are common in long-term dialysis patients and are risk factors for unfavorable outcomes. The associations between pretransplant levels of MBD surrogates and outcomes after kidney transplantation are not clear.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Data from the Scientific Registry of Transplant Recipients up to June 2007 were linked to the 5-year (July 2001-June 2006) cohort of a large dialysis organization in the United States. All dialysis patients who received a kidney transplant during this period were identified and divided into groups according to increments of pretransplant MBD markers. Unadjusted and multivariate adjusted predictors of transplant outcomes were examined.

RESULTS

The 11,776 patients were aged 47 ± 14 years and 39% were women. Compared with recipients with pretransplant time-averaged serum alkaline phosphatase of 80-120 U/L, recipients with pretransplant serum alkaline phosphatase of 120-160 and ≥160 U/L had 49% and 64% higher graft failure censored all-cause mortality in multivariable adjusted models. There was no significant association between time-averaged serum alkaline phosphatase categories and risk of death censored graft failure, delayed graft function (DGF), or acute rejection (AR). Compared with recipients with pretransplant time-averaged serum parathyroid hormone (PTH) levels of 150-300 pg/ml, there was no significant association with graft censored death among recipients with pretransplant serum PTH ≥800 pg/ml. In addition, the risk of graft failure, DGF, and AR did not show any association with time-averaged serum intact PTH level. There was no significant association between time-averaged serum calcium categories and risk of graft failure censored death, DGF, and AR.

CONCLUSIONS

In this cohort, hemodialysis patients with pretransplant serum alkaline phosphatase >120 U/L have unfavorable post-transplant mortality, whereas there was no association between serum PTH and serum calcium levels and post-transplant outcomes.

Avoiding harm in peritoneal dialysis patients

This review is focused on minimizing complications and avoiding harm in peritoneal dialysis (PD) patients. Issues related to planning for PD are covered first, with emphasis on PD versus hemodialysis outcomes. Catheter types and insertion techniques are described next, including relevant recommendations by the International Society for Peritoneal Dialysis. A brief review of both noninfectious and infectious complications follows, with emphasis on cardiovascular and metabolic complications. Finally, recommendations for preventing PD-related infections are provided. In conclusion, with proper catheter insertion technique, good training, and attention to detail during the tenure in PD, excellent outcomes can be obtained in a well-informed motivated patient.

Mortality associated with dose response of erythropoiesis-stimulating agents in hemodialysis versus peritoneal dialysis patients

BACKGROUND

Several studies have shown an association between erythropoietin-stimulating agent (ESA) responsiveness and mortality in chronic kidney disease (CKD) patients. In our present study, we examined the association between prescribed ESA dose and mortality in peritoneal dialysis (PD) and hemodialysis (HD) patients. We hypothesized that PD patients received lower ESA dose for the same achieved hemoglobin compared to HD patients and that ESA dose-mortality associations were different between PD and HD patients.

METHODS

We compared the prescribed doses of ESA between 139,103 HD and 10,527 PD patients treated in DaVita dialysis clinics from 7/2001 through 6/2006 using adjusted Poisson regression and examined mortality-predictability of prescribed ESA dose and ESA responsiveness index (ESA/hemoglobin) in PD and HD with follow-up through 6/2007 using Cox regression models.

RESULTS

Poisson adjusted ratio of ESA dose of HD to PD was 3.6 (95% CI 3.5-3.7). In PD patients, adjusted all-cause death hazard ratios (HR) for ESA doses of 3,000-5,999, 6,000-8,999 and ≥9,000 U/week (reference <3,000 U/week) were 0.97 (0.87-1.07), 0.85 (0.76-0.95) and 1.08 (0.98-1.18), respectively; whereas in HD patients across commensurate ESA dose increments of 10,000-19,999, 20,000-29,999 and ≥30,000 U/week (reference <10,000 U/week) were 1.14 (1.11-1.17), 1.54 (1.50-1.58) and 2.15 (2.10-2.21), respectively. In PD and HD patients, the adjusted death HR of the 4th to 1st quartile of ESA responsiveness index were 1.14 (1.04-1.26) and 2.37 (2.31-2.43), respectively.

CONCLUSIONS

Between 2001 and 2006, most PD patients received substantially lower ESA dose for same achieved hemoglobin levels, and low ESA responsiveness was associated with higher mortality in both HD and PD patients.