perspectives in peritoneal dialysis
DESCRIPTION
Updated Nephrology Trainee Seminar Presentation on the Qualitative Aspects of Peritoneal Dialysis - September 2014TRANSCRIPT
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Perspectives on Peritoneal Dialysis
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Overview
• Prevalence of PD as an RRT Modality– Internationally and Locally
• Factors influencing PD utilisation– Survival Data / Residual Renal Function– Acute Unplanned PD– PD in Acute Kidney Injury– “PD First”
• PD as a bridge to Transplantation• Assisted PD
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International Variation in Modality
Rates of PD in developing world increasing 8-10%/annum
Developing countries noted prevalence increase by 300% past 10 years.
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International Variation in PD
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Prevalent Patients in UK by RRT Modality (1997-2010)
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Where does PD fit into a Renal Replacement Programme?
Low Clearance
Peritoneal Dialysis
Haemo-dialysis
Transplantation
Conservative Therapy
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RRT start at 90 days by modality (2009-2010) (Renal Registry 2011)
Area HD (%) PD (%) Transplant (%)
England (N =5605) 67 18.6 8.7
Leicester (N = 217) 67.5 18.7 13.8
Chelmsford (N=47) 53.3 42.2 4.4
N. Ireland (N=172) 90.7 6.0 3.3
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RRT start at 90 days by modality (2011-2012) (Renal Registry 2013)
Area HD (%) PD (%) Transplant (%)
England (N =5797) 70.1 18.6 9.1
N. Ireland (N=205) 73.5 14.5 12.4
How do you keep competing RRT modalities viable in a renal unit?
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Is there potential competition with other Home Dialysis Modalities?
(Almost) Mutually Exclusive Demographics• Age / Sex / Cause of ESRD• Co-morbid Profile• ESRD Vintage
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Why such variation in PD Therapy provision?
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Factors influencing PD utilization
1. Financial factors• Reimbursement rates
2. Centre factors• Dialysis staff opinion or bias• PD experience• HD availability
3. Patient factors• Opinion of primary care physician• Geography• Timing of nephrology referral
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4. Socio-economic factors• Structure of dialysis program• Number of dialysis centres
5. Cultural factors• Attitude towards chronic disease• Attitude towards home therapy
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Peritoneal Dialysis vs. Haemodialysis
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Mortality Rates between Modality
Mortality figures between modality originally noted conflicting ‘survival advantage’ results in PD patients compared with HD.– Most found survival advantage lost after first 2
years of therapy– Raised suggestions about elective switch
from PD to HD
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CVC impacts association between modality and survival◻ 1-year mortality ⬜HD-AVF/AVG and PD similar⬜HD-CVC 80% higher than PD
◻ Use of CVCs in incident HD patients largely accounts for the early survival benefit seen with PD
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Mortality Rates between Modality
Mortality rates between ‘planned’ and ‘unplanned’ dialysis often discrepant.
‘Peritoneal dialysis and haemodialysis associate with similar survival among incident dialysis patients who initiate dialysis electively, as outpatients, after at least 4 months of predialysis care…’
Quinn et al. JASN (2011)
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What about Residual Renal Function?
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Role of Residual Renal FunctionResidual renal function in either modality is
associated with a lower risk of death.Peritoneal Dialysis
NECOSAD-2 Study (based on renal kt/V)JASN (2004); 15: 1061–1070
HaemodialysisShemin et al. (Based on Measured Creatinine Clearance)
AJKD (2001) 38: 85-90.
Several surrogate markers also associated with RRF e.g. Phosphate Control / Anaemia
CONTRAST Study CJASN (2011)
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Peritoneal Dialysis in Acute Kidney Injury
Do we have enough evidence to use it?
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PD in AKI - In terminal decline?
• Acute PD associated with higher mortality in patients with AKI secondary to falciparum malaria.
Phu et al. NEJM 2002
However many small trials in paediatric AKI have reported favourable results
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High Volume Peritoneal Dialysis in Intensive Care
Sao Paulo Experience (CJASN 2012)• Continuous 2 litre 60-80 minute exchanges
can achieve solute clearances comparable to intermittent daily HD or CVVH
• Recovery of renal function and mortality comparable to alternative dialysis modalities– But ICU Mortality with AKI remains high…– May not be so effective in hypercatabolic patients– Requires intact peritoneum + functional catheter
(~10% of cases had early mechanical complications)
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Delivering PD for AKI in Developing Countries
Helping deliver PD in Sub-saharan AfricaPapers published on work in Tanzania / Nigeria / Ghana showing respectable outcomes in small cohorts (Kilonzo et al PDI 2012)
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Is acute ‘unplanned’ PD feasible and safe?
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Potential Scenarios
◻ Low clearance patient wanting to start HD with an AVF⬜GFR now 7ml/min, AVF hasn’t matured or run out
of options for useful AVF creation
◻ Young patient presents @ ESRD, GFR 6ml/min, Hb 78 g/L, K/HCO3 normal, volume status OK, anorexia, fatigue
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What does Urgent PD require?
● Buy in from medical and surgical teams● Access to rapid education/orientation● Access to rapid PD insertion● Access to IPD post insertion
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How Quick can you use a PD Catheter?
Overcoming the need for a ‘break-in’ period
• No difference in rates of complications from instant use vs. waiting 3-5 days
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Experiences of Acute PD
123 patients starting Acute Unplanned Dialysis (2005-2010) (66 = PD , 57 = HD)44 patients died (36%) within 6 months
Mortality rates (all cause and cardiovascular) not significant difference between modality
HD Patients had higher risk of bacteraemia
Koch et al. NDT (2012) 27 (1):375-380.
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PD when all other access options are exhausted
Aitken et al. JVA 201462 patients with bilateral upper extremity stenoses• 8 patients switched to PD - 12 month
patency of 50%
However 11 received DCD transplants - 12 month patency 72%
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Peritoneal Dialysis as a Bridge to Transplantation
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Any influence on time to transplantation?
Dialysis modality doesn’t appear to influence time to transplant
Chalem et al. found a shorter waiting time for PD patients in Cox proportional models (RR 0.71, P < 0.0001)– statistical significance lost when taking into
account the transplant centre as a variable Kidney International (2005)
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Any influence on Transplant outcomes? (1)
Short Term (within 6months)– Patient and Graft survival about the same
regardless of modality
– PD Patients reported to have reduced rate of delayed graft function but increased risk of early graft failure
– Increased risk of graft thrombosis?• Varying size and methodology of studies reporting
association (such as Murphy et al. NDT 1994)
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Any influence on Transplant outcomes? (2)
USRDS Analysis
14,508 patients between July 2001 - June 2006 (86% Haemodialysis, 14% Peritoneal Dialysis)
Long Term Graft Function– No apparent difference in acute rejection episodes,
long-term graft survivals, or renal function.
Molnar et al CJASN 2012
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All cause mortality according to pre-transplant dialysis modality (Molnar et al. CJASN 2012)
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What about assisted PD?
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Weighing it all up…PROS
Enables a bridge to ‘self-care’ PD or ongoing PD in event of patient/carer fatigue
Reduced risks of PD peritonitis reported and comparable technique survival (Ayede et al BMC Nephol 2014)
CONSMay be associated with increased mortality and
difficulty in establishing ceiling of treatment in frailer patients
‘Hidden’ costs – trainers / carers / patients
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How should assisted PD influence dialysis service provision in the community?
Independent Patients suitable
for Home Therapy
Dependent Patients not suitable for Home
Therapy
aPD
PD
aPDPD
PD
“Pre aPD” Status
“Aspirational” Model
Reality?
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Summary
• PD service provision influenced by multiple non-medical factors (and physician preference!)
• PD and HD are intrinsically not equivalent cohorts and hard to compare.
• Some challenges remain as to the appropriate role of PD in dialysis programmes