Dr. Osama El-Shahat

Consultant Nephrologist Head of Nephrology Department

New Mansoura General Hospital (international) ISN Educational Ambassador

Agenda

Integrated Renal Care

Advantages of PD

Peritonitis

PD in AKI

PD cost

Conclusion

The word preitoneum refers to the Greek word “peritononion” and

means to stretch. Ancient Egypt were probably the first people to get

a look at the peritoneum

1st steps towards peritoneal dialysis.

4

Integrated Renal Care:The Concept

“Complementary Not Competitive” Coles 1998 “The right modality at the right time. Peter Blake, MD, John Burkart, MD

Early referral of patient With CKD to renal center

Pre-emptive Transplantation

PD as first option if medically suitable Allowing for patient chioce

Patient education program

HD Transplant

PD

Timely

referral

Timely

preparation

Best sequence of

PD, HD and TX

Therapy

management

Timely

Initiation

Therapy

transfer

Conclusion

Peritoneal dialysis is a safe, efficacious, and

complementary alternative to HD in the urgent-start

setting, and many urgent start programs have been

successfully established worldwide. Consideration

should be given to its future integration into a structured

and patient-centered dialysis program.

The Importance of Patient Education

Golper T. Patients education: can it maximize the success of therapy? Nephrol Dial Transplant .2001 :

(suppl 7):20-24.

The National Pre-ESRD Education Initiative Survey

After Pre-ESRD Education ,45 %Chose PD

and 33 %Actually Started PD

N = 2400 100

80

60

40

20

0

Choice of Modality Actual Modality Started US Incidence

Perc

enta

ge

of

Patients

PD

HD

Rioux J, Cheema H, Bargman JM, et al. Effect of an in-hospital chronic kidney disease education

program among patients with unplanned urgent-start dialysis. Clin J Am Soc Nephrol 2011;6:799.

Conclusion

Home dialysis is feasible after urgent dialysis start.

Education should be promoted among patient experiencing

acute- start dialysis.

228 Acute Start Between 2005-2009

Education program before discharge

132 In-center HD

71 Home

49 PD 22 HHD

25 Died

(before discharge)

Patients’ flow through the study

Rioux J, Cheema H, Bargman JM, et al. Effect of an in-hospital chronic kidney disease education

program among patients with unplanned urgent-start dialysis. Clin J Am Soc Nephrol 2011;6:799.

Physician Preference For Modality

Merighi JR, Schatell DR, Bragg-Gresham JL, et al. Insights into nephrologist training, clinical

practice, and dialysis choice. Hemodial Int 2012;16:242-251.

N=629

Distribution of nephrologists’ modality choice for themselves

Adapted from:

Merighi JR, Schatell DR, Bragg-Gresham JL, et al. Insights into nephrologist training,

clinical practice, and dialysis choice. Hemodial Int 2012;16:242-251.

49.4%

15.8% 20%

17.1%

7.4% 10%

0%

20%

33.2%

50%

60%

Jalisco (Mexico)New Zealand Netherlands Denmark Canada United States

% P

revale

nt

Pati

en

ts o

n P

D

Underutilization of Peritoneal Dialysis

U.S. Renal Data System. USRDS 2013 Annual Data Report.

Conclusions In conclusion, PD continues to be underutilized in

many countries, including the United States. There are

many factors that contribute to this underutilization

(e.g., modality, system, and patient-related factors).

Clin J Am Soc Nephrol 6: 447–456, 2011

Why to start with PD ?

0

1

2

3

4

5

6

7

8

0 6 12 18 24 30

RRF (ml/min/1

.73 m

2)

Months

CAPD HD-LF HD-HF

Lang et al, PDI 21:52-57, 2001

Preservation of residual renal function in CAPD, low flux & high flux HD

PD Patients Have an Initital Survival Advantage Relative to HD.

Danish Registry 2001

0

5

10

15

20

25

30

35

0.5 1 1.5 2 2.5 3 3.5 4

HD

PD

Time (years)

J Heaf, NDT 2002

4921 patients

Conclusions

Peritoneal dialysis seems to be associated with 48% lower

mortality than hemodialysis over the first 2 years of dialysis therapy

independent of modality switches or differential transplantation rates.

Clin J Am Soc Nephrol 8: 619–628, 2013.

Prospective study of 526 incident patients starting RRT. 1 year follow up. Univariate analysis:

The most common single reason for admission was creation of & complications to vascular access for HD.

The use of temporary vascular access for HD were associated with prolonged hospitalisation & repeated admissions.

Patients initially treated with HD rather than PD spent longer time in hospital & were more likely to be admitted.

Hospitalisation in the First Year of RRT for ESRD

Metcalfe Et Al. Q J Med 2003; 96: 899

Prevalence of anti-HCV Among Patients on Dialysis by Modality

Pereira KI 1997;51:981-999

7%

13%16%

19%

23%

31%

44%47%

50%

35%

25%

5%2%2%

0%

17%

8%

12%

34%

5%

15%

20%

0%

20%

40%

60%

McI

ntyre

Brugn

ano

Chan

Jonas

Cantu

Duss

ol

Barril

Neto

Selgas

Huang

Yoshid

a

HD PD

.Conclusions Dialysis modality selection significantly

influences the risk of HCV infection experienced

by end-stage renal failure patients in the Asia-

Pacific region. No such association could be

identified for HBV infection.

Results After Kidney Tx: Danish Registry 1990-1999

0 20 40 60 80

5 yr graft survival

5-day delayed function

10-day delayed function

Time to onset of function

HD

PD

*P<0,05

*

*

*

J. Heaf NDT 2002

Tx:1397, HD:877, PD:520

50

40

30

20

10

% DGF* 0

% never

dialysis-free following Tx

If DGF , time until dialysis

independence

(days)**

24.1%

8.6%

13.8%

7.8

16.8

50.0%

PD (n=56)

HD (n=58)

*p<0.05 **p<0.025

50

40

30

20

10

Effect of Dialysis Modality on Initial Graft Function

Fontan MP, et al, Renal transplantation in patients undergoing chronic peritoneal dialysis. Perit Dial Int 16:48-51, 1996.

Conclusions.

The study suggests that the

outcome of patients starting PD

after kidney transplant failure was

similar to those starting HD.

Therefore, PD can be regarded to

be a good treatment option for

patients returning to dialysis after

kidney transplant failure

Lifestyle Flexibility: Employment

1Merkus M, et al.: Am J Kidney Dis, 1997. 4Powe, N. RPA/REF Annual Meeting, 1997. 5Julius M, et al.: Arch

Intern Med, 1989. 6CENSIS, Italy, 1997. 7ALCER, Spain, 1997. 8ACOS, Germany, 1996.

% o

f P

ati

ents

Em

plo

yed

10%

20%

30%

40%

50%

70%

80%

60%

Merkus Choice Study

Julius CENSIS Alcer 0

1

4

5 6 7

HD

PD

% of patients employed within modality group

ACOS 8

Most observational data indicate that there is an initial survival advantage for patients with ESRD started on PD therapy. these include preservation of residual kidney function reduced infection risk improved patient satisfaction lowered health care costs

Results:

A total of 1321 patients were included. The mean age was 48.1 ± 15.3 years,

41.3% were female, and 23.5% with diabetes mellitus. The median (interquartile)

follow-up time was 34 (21–48) months. After adjusting for confounders, peritonitis

was independently associated with 95% increased risk of all-cause mortality (hazard

ratio, 1.95; 95% confidence interval: 1.46–2.60), 90% increased risk of

cardiovascular mortality (hazard ratio, 1.90; 95% confidence interval: 1.28–2.81)

and near 4-fold increased risk of infection-related mortality (hazard ratio, 4.94; 95%

confidence interval: 2.47–9.86). Further analyses showed that peritonitis was not

significantly associated with mortality within 2 years of peritoneal dialysis initiation,

but strongly influenced mortality in patients dialysed longer than 2 years.

Conclusions:

Peritonitis was independently associated with higher risk of all-cause,

cardiovascular and infection-related mortality in peritoneal dialysis patients, and its

impact on mortality was more significant in patients with longer peritoneal dialysis

duration.

CONCLUSION

We have demonstrated that direct xenograft of HUMSCs into the rat intraperitoneum

effectively prevented PD/MGO 3W-induced abdominal cocoon formation,

ultrafiltration failure, and peritoneal membrane alterations such as peritoneal

thickening, fibrosis, and inflammation. These findings provide a basis for a novel

approach with therapeutic benefits in the treatment of encapsulating peritoneal

sclerosis.

PD … the modality first used for the treatment of KI

Acute PD dosing guidelines adapted from ISPD guidelines

Conclusion This review clearly shows that PD is a simple, safe,

and efficient way to correct metabolic, electrolyte,

acid – base, and volume disturbances generated by

AKI and it can be used as an RRT modality to treat

AKI, both in and out of the ICU setting.

Transports

Hospitalisation

Pharmaceuticals

(e.g. EPO)

Equipment costs

(Lease, depreciation,

maintenance)

Disposables

Labor

Water Treatment

Infrastructure

Transports

Hospitalisation

Pharmaceuticals

(e.g. EPO)

Equipment costs

Disposables

Labor

Infrastructure

Schematic RRT Cost Comparison Available

Modalities

Modality Cost Comparison In KSA

Results From the regional population ([9,700,000 inhabitants), 1067 patients (34.3 %

females) initiating dialysis were identified, of whom 82 % underwent only

hemodialysis (HD), 13 % only peritoneal dialysis (PD) and the remaining 5 % both

treatments. Direct healthcare costs/patient were € 5239, € 12,303 and € 38,821 (€

40,132 for HD vs. € 30,444 for PD patients) for the periods 24–12 months pre-dialysis,

12–0 months pre-dialysis, and in the first year of dialysis, respectively.

Conclusions This study highlights a significant economic burden related to CKD and

an increase in direct healthcare costs associated with the start of dialysis, pointing to

the importance of prevention programs and early diagnosis.

Conclusion The decline of PD in the Netherlands cannot be explained by medical reasons.

Whatever the causes, it has resulted in a downward spiral where loss of experience

and insufficient knowledge on important pathophysiological and other related

pertinent issues of this home dialysis modality have resulted in an almost

exclusive attention to haemodialysis. This happened while it is now evident that

patient survival on PD is at least similar or even better than that on haemodialysis,

also in the long-term. To change the tide, the quality of education of patients,

nurses and doctors needs updating. The above review is an effort by a group of

professionals involved in peritoneal dialysis to revitalise the interest of the

Nephrology and Internal Medicine communities in up-to-date PD. Important

conclusions are that patient education can be improved, that PD leads to better

preservation of residual kidney function, that the value of small uraemic toxin

removal is less important than good management of the hydration state of patients,

that peritonitis is a manageable problem, that EPS is a lesser problem than it used

to be, and that imminent EPS can be identified before the clinical signs and

symptoms appear. Therefore it can be concluded that PD is an excellent chronic

dialysis modality that deserves a larger penetration than is currently present.

Integrated care approach is the optimal treatment for ESRD.

PD is the modality of choice to start RRT if kidney Tx not

available.

PD is the solution for overcrowded dialysis units.

PD is underutilize, more effort from nephrologists,

government and local companies to support PD program.

Conclusion

Clin J Am Soc Nephrol 7: 887 – 894, 2012. doi: 10.2215/CJN.11131111

Conclusion High- volume peritoneal dialysis is effective for a

selected AKI patient group, allowing adequate

metabolic and fluid control. Age, sepsis, and urine

output as well as nitrogen balance and ultrafiltration

after three high volume peritoneal dialysis sessions

were associated significantly with death.

Why PD ?

Transplantation After

PD Vs HD