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

Comparison of outcomes between kidney transplant-naïve and post-transplant graft failure peritoneal dialysis patients

BACKGROUND

This study was conducted to compare clinical outcomes between transplant-naïve peritoneal dialysis (PD) patients and those returning to PD after a failed allograft.

METHODS

In this retrospective cohort study during 2006 and 2016, we included a total of 786 patients on chronic PD. Of them 679 were transplant-naïve, 75 patients underwent a successful transplantation, and 32 patients returned to PD after a failed kidney allograft. Baseline demographics and clinical characteristics were analyzed in relation to the outcomes of all-cause mortality and peritonitis rate. We employed the Kaplan-Meier method and Cox proportional hazards model to evaluate survival, while Poisson regression was utilized to estimate rate ratios for peritonitis.

RESULTS

During a median follow-up of 6.37 years, 56.68 % death and 146.62 episodes of peritonitis/patient-year were observed. Compared with patients who received a kidney graft, transplant-naïve patients were older, more with diabetes and having higher mortality (58.6 ± 15.8, 40.5 % and 57.73 %, p < 0.0001). After accounting for age, gender, and comorbidities, the adjusted hazards ratios were 0.26 (95 % CI 0.13-0.53) in patients with a functioning graft and 1.12 (95 % CI 0.61-2.06) in patients returning to PD after graft failure, compared respectively with concurrent PD patients without kidney transplant. The adjusted rate ratio of peritonitis in patients resuming PD after graft failure was 0.55 (95 % CI: 0.22-1.14) compared to those without kidney transplant.

CONCLUSIONS

Patients restarting PD after graft failure exhibited clinical outcomes comparable to transplant-naïve PD patients. These findings support the feasibility of reinitiating PD after kidney transplant fails.

Budgetary impact of increasing use of peritoneal dialysis over haemodialysis in Spain

BACKGROUND

Chronic kidney disease (CKD) represents a significant public health concern, due to its high prevalence and incidence, as well as its substantial socio-economic costs. In Spain, estimates suggest that the direct healthcare costs of CKD will increase by 13.8% from 2022, which is why the cost of kidney replacement treatment (KRT) programs efficiency and sustainability is under constant analysis. Our analysis aimed to estimate the cost associated with peritoneal dialysis (PD) compared to hemodialysis (HD) from the Spanish National Health System (NHS) perspective and to evaluate the budgetary impact of an increase in the use of PD in our healthcare system environment.

METHODS

The number of patients eligible for KRT was calculated based on the total Spanish population and the incidence and prevalence of patients with end-stage renal disease (ESRD). Patients receiving each modality, type of dialysis, and location of dialysis were estimated. The annual costs of each dialysis modality were calculated and included the cost of dialysis sessions and additional costs (including the cost of peritoneal and vascular access, hospitalisation costs due to potential complications of dialysis, cost of health care personnel, and cost of health care transport used by patients). Population data and costs (€, 2024) were obtained from the Spanish databases and a nephrologist validated the assumptions. Budget impact analysis assessed the incremental budget impact between the current scenario and the alternative scenario, where 30% of incident patients on scheduled HD would receive PD.

RESULTS

We estimated that in Spain, there are 27,281 prevalent dialysis patients (3,141 receiving PD and 24,140 receiving HD/HDF) and 6,052 incident dialysis patients (1,173 receiving PD and 4,879 HD/HDF). The cost of dialysis amount to €1,555,573,771 (€141,361,374 PD and €1,414,212,397 to HD) in the current scenarios and to €1,540,584,011 (€167,593,157 PD and €1,372,990,854 HD) in the alternative scenario, resulting in a saving of €14,989,760 when 30% of the patients scheduled to receive HD would instead receive PD during the first year.

CONCLUSIONS

The increased use of PD in Spain improves the system's efficiency, generating significant savings in the treatment of ESRD patients from the NHS perspective.

Неімуноопосередковані детермінанти тривалості функціонування трансплантованої нирки

Незважаючи на успіхи щодо подовження тривалості функціонування трансплантованої нирки, вона складає, у середньому, лише 10-12 років. При цьому тривалість функціонування трансплантованої нирки прогресивно знижується вже після першого року трансплантації. Прогресуюче зниження функціональної здатності трансплантованої нирки обумовлюється двома основними групами причин: неімуноопосередкованими та імуноопосередкованими. Відстрочена функція трансплантата (ВФТ) є кількісним і якісним інтегральним проявом як імуноопосередкованих так і неімуноопосередкованих механізмів, котра суттєво впливає на короткострокові та довгострокові результати трансплантації. Питома вага кожної складової у конкретного реципієнта індивідуальна і змінюється протягом усього післятрансплантаційного періоду. Робіт, присвячених визначенню неімуноопосередкованих детермінант тривалості функціонування трансплантату загалом і виникнення ВФТ у тому числі, небагато. У цьому огляді систематизовані ключові неімуноопосередковані детермінанти як можливі терапевтичні мішені, що є визначальним для своєчасного початку лікування та подовження терміну функціонування трансплантованої нирки. Очевидно, що на сьогодні максимального результату щодо тривалості функціонування трансплантованої нирки можна досягти встановивши терапевтичні мішені та ефективні способи впливу на імуно та неімуноопосередковані складові як донора так і реціпієнта. Мета аналітичного огляду – визначити неімуноопосередковані детермінанти ретро та проспективне вивчення яких дозволить запропонувати терапевтичні мішені для подовження функціонування трансплантованої нирки.

Delayed graft function after renal transplantation

Background information

Delayed graft function (DGF), defined as the need for dialysis within the first week of a kidney transplant, is a common complication, particularly in extended criteria donor transplants, where its incidence ranges from 21 to 31%.

Objectives

We observed a prolonged case of DGF in a 47-year-old patient with chronic kidney disease (CKD) resulting from diabetic nephropathy. The patient, classified in a moderate immunologic mismatch group, received a marginal deceased donor kidney.

Results

For the first 4 weeks post-transplantation, graft function was impaired. After 29 days of anuria, the transplanted kidney began to recover. The literature review found few clinical cases of DGF extending beyond 1 month. Our patient had several risk factors for DGF, including diabetes mellitus, pre-transplant hemodialysis, and moderate immunologic mismatch. Additionally, the marginal graft increased the risk of ischemia-reperfusion injury and glycocalyx damage. However, it remains unclear how these factors influenced the duration of DGF. The exact cause of the extended DGF in this case remains unknown. Although the literature identifies key risk factors for DGF, data on factors leading to prolonged kidney dysfunction are lacking. Therefore, decisions to remove a non-functioning transplanted kidney should not be made hastily.

Non-Invasive Biomarkers for Early Diagnosis of Kidney Allograft Dysfunction: Current and Future Applications in the Era of Precision Medicine

Kidney transplantation stands as the preferred treatment for end-stage kidney disease, significantly improving both the quality and longevity of life compared to dialysis. In recent years, the survival rates for patients and grafts have markedly increased thanks to innovative strategies in desensitization protocols for incompatible transplants and advancements in immunosuppressive therapies. For kidney transplant recipients, preventing allograft rejection is of paramount importance, necessitating the use of immunosuppressive medications. Regular follow-up appointments are essential, as monitoring the function of the kidney allograft is critical. Currently, established biomarkers such as serum creatinine, estimated Glomerular Filtration Rate (eGFR), proteinuria, and albuminuria are commonly employed to assess allograft function. However, these biomarkers have limitations, as elevated levels often indicate significant allograft damage only after it has occurred, thereby constraining treatment options and the potential for restoring graft function. Additionally, kidney biopsies, while considered the gold standard for diagnosing rejection, are invasive and carry associated risks. Consequently, the identification and development of new, sensitive, and specific biomarkers like dd-cfDNA, microRNAs (e.g., miR-21, miR-155), and sCD30 for allograft rejection are crucial. To tackle this challenge, intensive ongoing research employing cutting-edge technologies, including "omics" approaches, like genomic techniques, proteomics, or metabolomics, is uncovering a variety of promising new biomarkers.

The assesement of the long-term effects of kidney transplantation, including the incidence of malignant tumors, in recipients operated on between 2006 and 2015 - a cohort study and literature review

<b>Introduction:</b> Chronic kidney disease (CKD) is a global public health problem, occurring more frequently in developed countries. In Poland, it affects approximately 4 million people, which constitutes 10.8% of the population. End-stage renal disease (ESRD) requires renal replacement therapy - dialysis therapy or kidney transplantation. Kidney transplantation, supported by immunosuppressive therapy, is the preferred method of treating ESRD, improving the quality and length of life of patients.<b>Aim and Methods:</b> The aim of the study was to determine the long-term effects of kidney transplantation, including proper graft function, the frequency of adverse effects of immunosuppressive therapy, the degree of patient compliance with therapeutic recommendations, and the incidence of malignancies. A survey was conducted in a group of 137 patients who underwent kidney transplantation between 2006 and 2015. Hospitalization data were also analyzed, including age, body weight and blood type of the recipient.<b>Results:</b> Of the 137 patients studied, 61 were women and 76 were men. The mean age of the patients was 45.1 years. The most common etiology of CKD was glomerulonephritis. After kidney transplantation, 86.86% of patients declared normal graft function. Post-transplant weight gain was noted in 75.18% of patients. 11.68% of recipients developed malignancies, with an average time from transplantation to diagnosis of 5.1 years. Of the patients with cancer, 93.75% maintained normal graft function.<b>Conclusions:</b> Long-term effects of kidney transplantation are satisfactory, with a high percentage of patients maintaining normal graft function. Complications associated with immunosuppressive therapy are comparable to literature data. It is necessary to increase patient awareness of modifiable risk factors to improve treatment outcomes. The incidence of malignancy after transplantation is lower than in the literature, but the methodological limitations of the study must be taken into account. Cancer treatment had no significant effect on graft function in most cases.

Continuous ambulatory peritoneal dialysis technique failure in adult patients treated at a tertiary hospital in central South Africa: a retrospective analytical study

BACKGROUND

Continuous ambulatory peritoneal dialysis (CAPD) is one of the kidney replacement therapy (KRT) modalities used in patients with kidney failure. It is the preferred modality in most resource-limited settings as it is more accessible and cost-effective. CAPD technique failure remains a challenge and is associated with an increased risk of morbidity and mortality. We aimed to describe the sociodemographic and clinical characteristics, CAPD survival rate and the reasons for CAPD technique failure over a five-year period among adult patients on CAPD at a tertiary hospital in South Africa.

METHODS

We conducted a retrospective analytical study reviewing files of patients with end-stage kidney disease (ESKD) whose peritoneal dialysis (PD) catheter was removed, or who died with a functioning PD catheter while on the PD program at Universitas Academic Hospital in Bloemfontein, South Africa, from 01 January 2015 until 31 December 2019. The demographic, clinical and laboratory data were collected from patients' medical records. Clinical outcomes were technique failure and survival.

RESULTS

Ninety-one patient records met the inclusion criteria of whom 51 (56.0%) were male. The median age at commencement of PD was 40 years (interquartile range [IQR] 18-58). Fifty-one (57.3%) patients were single and 64 (70.0%) were unemployed. Hypertension was the leading cause of ESKD (n = 47; 51.6%), followed by human immunodeficiency virus- (HIV-) associated conditions (n = 18; 19.8%). Technique failure rates at 1-, 2-, 3-, 4- and 5-years post-PD initiation were 31.9%, 35.2%, 13.2%, 8.8% and 11.0%, respectively. The 5-year survival rate was 63.7% (n = 58), with a median survival time of 26 months (IQR 1-54). Peritonitis was the leading cause of technique failure (n = 52; 57.1%), and almost a third (n = 29 (31.9%)) had a fatal outcome. Younger age and using the Dianeal® PD system were associated with an increased likelihood of technique failure. No other sociodemographic, laboratory and clinical factors were associated with the development of technique failure or death.

CONCLUSIONS

PD-associated peritonitis is the primary cause of technique failure, followed by sudden unexpected death occurring at home. Preventive measures need to be adhered to in order to avoid high rates of peritonitis.

Effect of Pretransplant Dialysis Method and Vintage on Early Clinical Outcomes of Kidney Transplantation

BACKGROUND

Pre-transplantation dialysis duration and modality may affect patients' long-term (mortality and graft failure) and short-term (delayed graft function) outcomes after kidney transplantation. We aimed to assess the impact of the method and duration of dialysis therapy on the graft function in the first 6 months post-transplant.

METHODS

The analysis included 122 kidney transplant patients (109 from a deceased donor and 13 from a living donor). Before transplantation, 91 were on hemodialysis (HD), 19 were on peritoneal dialysis (PD), and 9 received preemptive transplants. The incidence of delayed graft function (DGF) and creatinine levels at discharge and 6 months after transplantation were assessed.

RESULTS

PD and HD patients did not differ in age, number of mismatches, and cold ischemia time (CIT), but they had a significantly shorter dialysis vintage (18.3 ± 25.7 vs 39.6 ± 34.3 months, P = .01) and a lower incidence of DGF (5% vs 37%, P = .006). The duration of hospitalization and creatinine concentration at discharge and after 6 months were similar. Preemptively transplanted patients had a significantly shorter CIT (ND vs DO - 576 ± 362 vs 1113 ± 574, P = .01; ND vs HD - 576 ± 362 vs 1025 ± 585 minutes, P = .01). DGF did not occur in any of the patients transplanted preemptively. They had slightly shorter hospitalization times and, compared to HD, better graft function at discharge. After 6 months, creatinine levels were comparable to HD and PD. Patients dialyzed for less than 12 months, regardless of the method, had a lower incidence of DGF.

CONCLUSIONS

Peritoneal dialysis and a short duration of pre-transplant dialysis may improve the early results of kidney transplantation.

Risk Factor Analysis for Long-Term Graft Survival Following Pediatric Kidney Transplantation: The Importance of Pretransplantation Time on Dialysis and Donor/Recipient Age Difference

Recognizing risk factors that may negatively affect long-term graft survival following pediatric kidney transplantation is a key element in the decision-making process during organ allocation. We retrospectively reassessed all cases of pediatric kidney transplantation performed in our center in the last 20 years with the aim of determining baseline characteristics that could be identified as prognostic risk factors for long-term graft survival. Between 2001 and 2020, a total of 91 kidney transplantations in children under the age of 18 years were undertaken in our center. Early graft failure was observed in six of the 91 patients (7%). The median follow-up of the remaining 85 children was 100 months, and the overall kidney graft survival rates at 5, 10, 15 and 20 years were 85.2%, 71.4%, 46.0% and 30.6%, respectively. Small children with a body surface area of <1 m2 were significantly associated with better long-term graft survival outcomes, while adolescents aged more than twelve years showed poorer graft survival rates than younger children. Body surface area of the recipient of ≥1 m2, pretransplantation duration of the recipient on dialysis ≥18 months, hemodialysis prior to transplantation and donor/recipient age difference of ≥25 years were significantly associated with poorer long-term graft survival.

Percutaneous Onsite Insertion of Catheter for Peritoneal Dialysis - A New Method Introduction in the Country

Peritoneal dialysis (PD) is one of the options for renal replacement therapy (RRT) in the end stage renal disease (ESRD) patients. Compared to hemodialysis (HD), patients on PD experience a greater sense of well-being, an improved steady state in terms of extracellular fluid volume shifts and hemodynamics and it is preferred method for patients with problematic vascular access, bleeding tendencies, heart failure and elderly patients. In order to perform PD, a tunneled catheter should be placed through the abdominal wall and into peritoneal space, with positioning of the catheter within the most dependent portion of pelvis. Currently, there are several techniques available for PD catheter placement: open surgery, laparoscopic and percutaneous. We present for the first time in our country a case of 65 year old male patient to whom percutaneous onsite insertion of peritoneal catheter was performed. The idea is to emphasize that sometimes this should be a method of choice for RRT, especially in patients where general anesthesia should be avoid. Compared to other methods, percutaneous insertion is a simple procedure with no need for general anesthesia, and the benefits of quick recovery, earlier ambulation, and less delay in catheter placement.

Choice of the Dialysis Modality: Practical Considerations

Chronic kidney disease and the need for kidney replacement therapy have increased dramatically in recent decades. Forecasts for the coming years predict an even greater increase, especially in low- and middle-income countries, due to the rise in metabolic and cardiovascular diseases and the aging population. Access to kidney replacement treatments may not be available to all patients, making it especially strategic to set up therapy programs that can ensure the best possible treatment for the greatest number of patients. The choice of the "ideal" kidney replacement therapy often conflicts with medical availability and the patient's tolerance. This paper discusses the pros and cons of various kidney replacement therapy options and their real-world applicability limits.

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.

Employment and ability to work after kidney transplantation in the Netherlands: The impact of preemptive versus non-preemptive kidney transplantation

BACKGROUND

Work can have a major positive impact on health and wellbeing. Employment of kidney transplant recipients (KTR) of working age is much lower than in the general population. The first aim of this study was to examine the impact of a preemptive kidney transplantation (PKT) on employment, in addition to other possible influencing factors. The second aim was to explore differences in work ability, absenteeism and work performance among employed KTR with different types of transplantations.

METHODS

A cross-sectional survey study was conducted between 2018 and 2019 in nine Dutch hospitals. PKT as potential predictor of employment was examined. Furthermore, work ability, absenteeism and loss of work performance were compared between employed preemptive recipients with a living donor (L-PKT) and non-preemptive recipients with a living donor (L-nPKT) and with a deceased donor (D-nPKT).

RESULTS

Two hundred and twenty four KTR participated; 71% reported having paid work. Paid work was more common among PKT recipients (82% vs. 65% in L-nPKT and 55% in D-nPKT) and recipients who were younger (OR .950, 95%CI .913-.989), had no comorbidities (1 comorbidity: OR .397, 95%CI .167-.942; 2 comorbidities: OR .347, 95%CI .142-.844), had less fatigue (OR .974, 95%CI .962-.987) and had mentally demanding work tasks (only in comparison with physically demanding tasks, OR .342, 95%CI .145-.806). If recipients were employed, D-nPKT recipients worked fewer hours (mean 24.6±11.3 vs. PKT 31.1±9.6, L-nPKT 30.1±9.5) and D-nPKT and L-nPKT recipients received more often supplemental disability benefits (32 and 33.3%, respectively) compared to PKT recipients (9.9%). No differences were found for self-reported ability to work, sick leave (absenteeism) and loss of work performance with the exception of limitations in functioning at work.

CONCLUSIONS

Preemptive kidney transplantation recipients with a kidney from a living donor are employed more often, work more hours per week (only in comparison with D-nPKT) and have a partial disability benefit less often than nPKT recipients. More knowledge regarding treatments supporting sustainable participation in the labor force is needed as work has a positive impact on recipients' health and wellbeing and is also beneficial for society as a whole.

Peritoneal dialysis in the modern era

The practice and clinical outcomes of peritoneal dialysis (PD) have demonstrated significant improvement over the past 20 years. The aim of this review is to increase awareness and update healthcare professionals on current PD practice, especially with respect to patient and technique survival, patient modality selection, pathways onto PD, understanding patient experience of care and use prior to kidney transplantation. These improvements have been impacted, at least in part, by greater emphasis on shared decision-making in dialysis modality selection, the use of advanced laparoscopic techniques for PD catheter implantation, developments in PD connecting systems, glucose-sparing strategies, and modernising technology in managing automated PD patients remotely. Evidence-based clinical guidelines such as those prepared by national and international societies such as the International Society of PD have contributed to improved PD practice underpinned by a recognition of the place of continuous quality improvement processes.

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.

A Quality Improvement Process to Increase and Sustain a Peritoneal Dialysis Programme in the United Kingdom

INTRODUCTION

Peritoneal dialysis (PD) remains underutilised in the West. The proportion of patients in the UK starting renal replacement therapy (RRT) with PD fell from 7.2% in 2011 to 6.0% in 2016. At our centre, 8.4% of dialysis patients received PD in April 2014. Evidence suggests that home dialysis improves patient clinical outcomes; therefore, a target was agreed to achieve 25% of dialysis patients receiving PD by 2018.

METHODS

A rapid improvement process was introduced, as a quality improvement tool, to increase and sustain the PD programme. With multidisciplinary team support for PD growth, a nephrologist was trained to insert PD catheters. Nurses were trained to provide patients with balanced pre-dialysis information and discuss alternative dialysis modalities with haemodialysis (HD) patients. The "Acceptance, Choice and Empowerment" project raised awareness of home therapy choices, using a peer educator model specifically for ethnic minority patients. Lean methodologies were used to ensure continuous quality improvement.

RESULTS

PD uptake increased from 37 to 84 patients, giving a PD penetration increase from 8.4% to 19.1% between April 2014 and March 2018. Catheter insertions increased from 94 at the end of QI Period 1 to 185 at the end of QI Period 2, representing a 97% increase, with the medical/surgical split remaining stable. Peritonitis rates remained stable, and PD drop off to HD reduced from 52% to 41% during the same period.

CONCLUSIONS

By implementing a rapid improvement process and embedding a quality improvement programme, the number of incidents and prevalent PD patients increased and was sustained.

Patient Selection and Planning for Image-Guided Peritoneal Dialysis Catheter Placement

Image-guided percutaneous peritoneal dialysis (PD) catheter insertion has become increasingly relied upon to provide urgent access for late presenting kidney failure patients, to overcome surgical backlogs and limited operating room access, to avoid general anesthesia in high-risk patients, and, by itself, as an alternative approach to surgical PD access. Advanced planning for the procedure is essential to assure the best possible outcome. Appropriate selection of patients for percutaneous PD catheter placement, choosing the most suitable catheter type, determining insertion and exit site locations, and final patient preparations facilitate the performance of the procedure, minimizes the risk of complications, and improves the likelihood of providing a successful long-term peritoneal access.

Mechanical obstruction of the peritoneal catheter with ovarian fimbriae, case reports

The number of treated patients with peritoneal dialysis accounts for 2.8% of all kidney replacement therapy methods and constantly decreases. Peritoneal dialysis should be the first choice as the kidney function replacement treatment method in a transplantation waiting period. Besides all other possible infectious and mechanical complications of peritoneal catheter placement and maintenance, mechanical obstruction by ovarian fimbriae is very rare but potentially dangerous. We present four clinical cases (women 32–56 years) of mechanical obstruction of the peritoneal catheter by ovarian fimbriae during 2012–2014 in Clinical Hospital Merkur, Zagreb, Croatia. We use a laparoscopic technique with Čala trocar for peritoneal catheter placement in the right part of the Douglas cavity using a double-cuff Tenckhoff straight catheter. In our cases, all described obstructions were on the right side of the abdominal cavity. Only one patient had a displaced catheter. This problem was described only in a few case reports in which were presented with fluid exchange difficulties or initial vaginal secretion which can be easily mistaken for urinary incontinence. Mechanical complications connected with a peritoneal catheter can be successfully solved with laparoscopy intervention, which includes the ovary fimbriae obstruction.

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.

The case for Increased Peritoneal Dialysis Utilization in Low- and Lower-Middle-Income Countries

Peritoneal dialysis (PD) has several advantages compared to hemodialysis (HD), but there is evidence showing underutilization globally, especially in low-income and lower-middle-income countries (LLMICs) where kidney replacement therapies (KRT) are often unavailable, inaccessible, and unaffordable. Only 11% of all dialysis patients worldwide use PD, more than 50% of whom live in China, the United States of America, Mexico, or Thailand. Various barriers to increased PD utilization have been reported worldwide including patient preference, low levels of education, and lower provider reimbursement. However, unique but surmountable barriers are applicable to LLMICs including the excessively high cost of providing PD (related to PD fluids in particular), excessive cost of treatment borne by patients (relative to HD), lack of adequate PD training opportunities for doctors and nurses, low workforce availability for kidney care, and challenges related to some PD outcomes (catheter-related infections, hospitalizations, mortality, etc.). This review discusses some known barriers to PD use in LLMICs and leverages data that show a global trend in reducing rates of PD-related infections, reducing rates of modality switches from HD, and improving patient survival in PD to discuss how PD use can be increased in LLMICs. We therefore, challenge the idea that low PD use in LLMICs is unavoidable due to these barriers and instead present opportunities to improve PD utilization in LLMICs.

Continuation of Peritoneal Dialysis in Adult Kidney Transplant Recipients With Delayed Graft Function

INTRODUCTION

Peritoneal dialysis (PD) has been used increasingly in past decade. Many of these patients undergo transplantation and may require dialysis for delayed graft function (DGF). The outcomes of DGF based on the post-transplantation dialysis modality are not well known.

METHODS

We retrospectively reviewed all adult kidney transplant recipients (KTRs) from the University of Wisconsin School of Medicine and Public Health who developed DGF between November 2015 and April 2019. Patients were divided into those who received hemodialysis (HD) or PD during the DGF period. Immediate graft explant, DGF among living donor KTRs, or those requiring just a single dialysis treatment were excluded.

RESULTS

Of 224 KTRs with DGF during the study period, 167 fulfilled our selection criteria. There were 16 patients in the PD and 151 in the HD group. Baseline characteristics were similar between the two groups, except diabetes was more prevalent in the HD group. Five of 16 PD patients had to be transitioned to HD. There was no difference in DGF duration, hospital length of stay, infectious or surgical complications, rejection at various time periods, graft function at last follow-up, or graft failure. In multivariate analysis, only rejection within the first year of transplantation (hazard ratio [HR]: 4.26; 95% confidence interval [CI]: 1.20-15.08; P = 0.02) and post-surgical complications (HR: 3.79; 95% CI: 1.03- 13.91; P = 0.04) were associated with death-censored graft failure (DCGF). The use of PD for treatment of DGF was not associated with DCGF.

CONCLUSIONS

In carefully selected patients, PD can be continued safely for DGF without any effect on short-term or long-term transplant outcomes.

Peritoneal dialysis: the ideal bridge from conservative therapy to kidney transplant

Background

Kidney transplantation offers the best potential for full rehabilitation in patients with end-stage kidney disease who are treated with dialysis. However, due to organ shortage which is a universal phenomenon, most patients need to be maintained on a period of dialysis therapy before the prospect of transplantation. Peritoneal dialysis (PD) could be an ideal form of renal replacement therapy due to its favorable profile toward preservation of residual renal function, patient survival, lower overall burden on cardiovascular morbidity and infection risks.

Methods

With extensive experience in PD therapy from Hong Kong where PD-first is a mandatory health policy, we reviewed the literature and present current evidence that favors PD as an optimal form of bridging renal replacement therapy prior to kidney transplantation.

Results

PD provides a viable and advantageous form of renal reaplcement particularly in terms of preservation of residual renal function, patient survival and quality of life, and cost among many other factors. Potential misconceptions that PD-related peritonitis and dialysis inadequacy are potentially deterrent factors for initiating PD therapy are clarified.

Conclusion

PD is a practical and noninferior form of renal replacement that serves as an ideal bridge from conservative therapy to kidney transplantation.

Percutaneous insertion of peritoneal dialysis catheter is a safe and effective technique irrespective of BMI

BACKGROUND

A large body mass index (BMI) has been considered as a relative contraindication for percutaneous catheter insertion, although this technique has many advantages. Up to now, there are few studies on peritoneal catheter placement and obesity. The aim of this study was to determine whether patients with large BMI can also choose the percutaneous technique for peritoneal dialysis catheter insertion.

METHODS

One hundred eighty seven consecutive patients underwent peritoneal catheter insertions in the Chinese PLA General Hospital between January 1, 2015 and December 31, 2016, with 178 eligible cases being included in the analysis. Two groups were created based on the catheter insertion techniques, the percutaneous group (group P) and the surgical group (group S). Subgroups were created according to BMI > 28 or ≤ 28. The outcomes included catheter related complications and catheter survival.

RESULTS

Total infectious complication rates were significantly lower in group P than in group S. There were no significant differences in peritonitis rate between group P and group S (1.20% vs. 3.16% with P = 0.71 in early stage, and 4.82% vs. 11.58% with P = 0.11 in late stage). All other measured complications were similar between the two groups. Though the one-year infection-free catheter survival in group P was 7.5% higher than group S, the difference was not significant. The one-year dysfunction-free catheter survival, one-year dysfunction-and-infection-free catheter survival, and overall catheter survival were similar between the two groups. Subgroup analyses showed a superior one-year infection-free catheter survival of percutaneous technique in patients with BMI > 28, which was confirmed by Kaplan-Meier analysis.

CONCLUSIONS

Despite the challenges that may be encountered with patients who have a large BMI, the percutaneous technique seems to be a safe and effective approach to placing a peritoneal dialysis catheter.

Perspectives in Individualizing Solutions for Dialysis Access

The vascular access is the lifeline for the hemodialysis patient. Previous national vascular access guidelines have emphasized placement of arteriovenous fistulas in most hemodialysis patients. However, the new Kidney Disease Outcomes Quality Initiative guidelines for vascular access, soon to be published, will focus on a patient's end-stage kidney disease "life plan" and take a patient "first" approach. One of the major themes of the new Kidney Disease Outcomes Quality Initiative guidelines is selecting the "right access, for the right patient, at the right time, for the right reason". Given the availability of new advances in biomedical technologies, techniques, and devices in the vascular access field, this shift to a more patient-centered vascular access approach presents unique opportunities to individualize the solutions and care for patients requiring a dialysis vascular access. This review article will address 3 potential areas where there is an unmet need to individualize solutions for dialysis vascular access care: (1) biological approaches to improve vascular access selection and selection of therapies, (2) vascular access care for the post-transplant patient, and (3) vascular access disparities in race, gender, and the elderly patient.

Immunological Effects of a Single Hemodialysis Treatment

Immune disorders, involving both innate and adaptive response, are common in patients with end-stage renal disease under chronic hemodialysis. Endogenous and exogenous factors, such as uremic toxins and the extracorporeal treatment itself, alter the immune balance, leading to chronic inflammation and higher risk of cardiovascular events. Several studies have previously described the immune effects of chronic hemodialysis and the possibility to modulate inflammation through more biocompatible dialyzers and innovative techniques. On the other hand, very limited data are available on the possible immunological effects of a single hemodialysis treatment. In spite of the lacking information about the immunological reactivity related to a single session, there is evidence to indicate that mediators of innate and adaptive response, above all complement cascade and T cells, are implicated in immune system modulation during hemodialysis treatment. Expanding our understanding of these modulations represents a necessary basis to develop pro-tolerogenic strategies in specific conditions, like hemodialysis in septic patients or the last session prior to kidney transplant in candidates for receiving a graft.

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.

International Variations in Peritoneal Dialysis Utilization and Implications for Practice

In many countries, the use of peritoneal dialysis (PD) remains low despite arguments that support its greater use, including dialysis treatment away from hospital settings, avoidance of central venous catheters, and potential health economic advantages. Training patients to manage aspects of their own care has the potential to enhance health literacy and increase patient involvement, independence, quality of life, and cost-effectiveness of care. Complex reasons underlie the variable use of PD across the world, acting at the level of the patient, the health care team that is responsible for them, and the health care system that they find themselves in. Important among these is the availability of competitively priced dialysis fluid. A number of key interventions can affect the uptake of PD. These include high-quality patient education around dialysis modality choice, timely and successful catheter placement, satisfactory patient training, and continued support that is tailored for specific needs, for example, when people present late requiring dialysis. Several health system changes have been shown to increase PD use, such as targeted funding, PD First initiatives, or physician-inserted PD catheters. This review explores the factors that explain the considerable international variation in the use of PD and presents interventions that can potentially affect them.