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What is the Role of Peritoneal Dialysis in Optimising ESRD Patient Outcomes?
PD: Optimising Outcomes?
Slow Progression of Renal Disease
Prevent Additional Injury to Kidneys
Manage Co-morbid Conditions– Cardiovascular Disease – Diabetes– Anemia
Preserve Vascular Access Site
Maintain Proper Nutrition
Pre-dialysis Education for Patient
Pre-ESRD ESRD
Preserve Residual Renal Function
Prevent Additional Injury to Kidneys
Delay Long Term Complications
Manage Co-morbid Conditions– Cardiovascular Disease – Diabetes– Anemia
Preserve/Maintain Vascular Access Site
Maintain Proper Nutrition
Patient Social and Employment Rehabilitation
Blood Purification
Electrolyte and Acid Base Equilibrium
Goals Before and Following Initiation of Dialysis
Initiation of Dialysis
PD: Optimising Outcomes?
Non-Medical Factors that Impact on ESRD Modality Selection
• Financial/reimbursement
• Physician experience with both therapies
• Patient and family understanding of modality options
• Availability of resources (staff, finance, space, etc)
• Social factors
• Cultural habits
Nissenson AR, Kidney Int, 1993; 43 (Suppl. 40):S120-S127
PD: Optimising Outcomes?
Modality Selection and DistributionWhere Do We Want To Be?
PD: Optimising Outcomes?
Total survival is more important than survival on each therapy
HDTX
PD
“What patients want to know is which sequence of RR modalities will increase their survival as long as possible & this with the best Quality of Life”
Van Biesen 2000
PD: Optimising Outcomes?
Integrated Care Approach
“Start renal replacement therapy in ESRDpatients with PD, transfer them to HD when
problems with PD occur, and transplant them when the possibility exists”
Lameire N, et al, Seminar of Uro-Nephrology, (1999)
PD: Optimising Outcomes?
Integrated care concept:
• Patient survival and quality of life are two very important factors in the selection of a dialysis modality
• The majority of studies have compared the two modalities as « competitors » rather than as « complementary » techniques
• Since every RRT has a technical « drop-out », it is very likely that a patient will need several modalities during his lifetime and transfer from one technique to another will often be needed.
PD: Optimising Outcomes?
Integrated Therapy - questions
• Does the physician believe that all RRT modalities should be made available to each patient ?
• Should the patient have a free choice?
• Does each RRT modality have a role to play during the lifetime of a patient with renal failure ?
PD: Optimising Outcomes?
Reasons for Modality Switch
Van Biesen WE, Van Biesen WE, et alet al, , J Am Soc Nephrol 2000;11:116-125J Am Soc Nephrol 2000;11:116-125
Access CV Poor BP Personal Peritonitis Social Adequacy Leakage of Access CV Poor BP Personal Peritonitis Social Adequacy Leakage of Problems Problems Control Choice Exit-Site Problems or UF Dialysis Fluid Problems Problems Control Choice Exit-Site Problems or UF Dialysis Fluid
Haemodialysis to Peritoneal Dialysis Peritoneal Dialyisis to Haemodialysis Haemodialysis to Peritoneal Dialysis Peritoneal Dialyisis to Haemodialysis
Per
cent
of
patie
nts
Per
cent
of
patie
nts
50%
25%
14%
40%
25%
12% 11%
23%
0
10
20
30
40
50
PD: Optimising Outcomes?
Integrated ESRD Care
Residual Renal Function
Hemodialysis
Cre
ati
nin
e C
leara
nce
(ml/
min
)
20
15
10
5
0
Time on DialysisInitiation of
Dialysis
Peritoneal Dialysis
Transplant
PD
PD: Optimising Outcomes?
Challenges for PDChallenges for PD
• Can PD stand on an equal footing with HD?
• If PD is to be used for RRT, it must give equivalent results both for mortality and morbidity as does HD
PD: Optimising Outcomes?
Where is PD today?
• Similar survival to HD• PD is treatment of choice for children• Peritonitis and exit-site infection rates have been
reduced• Clearance targets can be achieved• Lower costs than HD• Good treatment prior to transplantation
PD: Optimising Outcomes?
PD as the Initial Form of Renal Replacement Therapy
• Better initial survival • Preserves residual renal function • Effective blood pressure and volume control• PD Transplant: reduced risk of early acute renal failure• Reduced risk of being infected by a blood borne virus• Delays the use of HD blood access sites • Quality of life
PD: Optimising Outcomes?
Initial Survival Advantage of PD - Canadian Results
30
40
50
60
70
80
90
100
0 6 12 18 24 30 36 42 48 54
PD
HD
Pat
ien
t S
urv
ival
(%
)
Months 10663 patients
P<0.001
Fenton AJKD 30:334-42, 1997
PD: Optimising Outcomes?
00.10.20.30.40.50.60.70.80.9
1
0 50 100 150
Months
Sur
viva
l
p=0.01 (log-rank)HD
PD to HD
Van Biesen JASN 2000; 11:116-25
Comparing Survival of “Integrated Care” Patients with HD Patients
PD: Optimising Outcomes?
Possible Causes
• Better preservation of residual renal function in PD.
Moist JASN 11:556-64, 2000
• The ”unphysiology” of HD.
Kjellstrand KI 7(S2):530-36, 1975
Lopot NDT 13(S6):74-78, 1998
• Monday HD mortality increased 58% relative to other days.
Bleyer KI 55:1553-9, 1999
PD: Optimising Outcomes?
PD as the Initial Form of Renal Replacement Therapy
• Better initial survival• Preserves residual renal function • Effective blood pressure and volume control• PD Transplant: reduced risk of early acute renal failure• Reduced risk of being infected by a blood borne virus• Delays the use of HD blood access sites • Quality of life
PD: Optimising Outcomes?
Preservation of residual renal function
Lysaght et al, ASAIO Trans, 1991; 37:598-604
Time on therapy in months
Res
idu
al C
reat
inin
e C
lear
ance
(ml/
min
)
0
1
2
3
4
5
0 6 12 18 24 30 36 42 48
CAPD (n=58)HD (n=57)
PD: Optimising Outcomes?
Preservation of residual renal function
0
1
2
3
4
5
6
7
8
0 6 12 18 24 30
Months
RR
F (
ml/
min
/1.7
3 m
2)
CAPD HD-LF HD-HF
Lang et al, PDI 21:52-57, 2001
PD: Optimising Outcomes?
Risk of RRF Loss
0 0.5 1 1.5 2 2.5 3
Time to Followup (yrs)
Female Sex
Non-white Race
Diabetes
Congestive Heart Failure
Serum Calcium (mg/ dl)
Hemodialysis
ACE I nhibitor
Calcium Channel Blocker
Odds Ratio Multivariate Analysis1843 patients
* p<0.05** p<0.01*** p<0.001
*****
****
***
******
*
Moist JASN 11:556-565, 2000
PD: Optimising Outcomes?
What are the benefits of preserving residual renal function?
Reduces Mortality
Contributes to total solute clearance (1 ml/min CrCl = 10 liter CrCl/week)
Facilitates volume control
Allows for more liberal diet and fluid
intake
Provides endocrine functions• Erythropoietin production• Ca++, phosphorus and vitamin D homeostasis
Improves 2-microglobulin and
middle molecule clearance
Improves nutritional status
Improves QoL
Increases total Na removal
Davies, S., 2000
PD: Optimising Outcomes?
Causes of RRF Preservation in PD
• Avoidance of Dehydration
• HD: production of inflammatory mediators by blood contact
McCarthy JASN 4:367, 1993
Lysaght ASAIO Trans 37:598-604, 1991
• Better clearance of middle molecules, lipophilic and proteinbound toxins.
PD: Optimising Outcomes?
n=33 n=21 n=24 n=16
0
1000
2000
3000
4000
5000
6000
Healthy Control
HD PD CRF Without dialysis
Ser
um
CR
P, n
g/m
lSerum CRP Values
Haubitz et al. PDI 16(2): 158-162, 1996
* *
* #*p<0.01 vs. control#p<0.01 vs. PD
PD: Optimising Outcomes?
PD as the Initial Form of Renal Replacement Therapy
• Better initial survival
• Preserves residual renal function
• Effective blood pressure and volume control
• PD Transplant: reduced risk of early acute renal failure
• Reduced risk of being infected by a blood borne virus
• Delays the use of HD blood access sites
• Quality of life
PD: Optimising Outcomes?
Difference in BP Control by Dialysis Modality
• The prevalence of hypertension in HD patients is approximately 80% vs. approximately 50% in PD patients.
• “Hypertension is not optimally controlled in HD and PD, but is better controlled in PD than HD”
• “Lower blood pressure in PD patients is attributed to the more successful achievement of dry weight by slower ultrafiltration”
Mailloux AJKD 1998; 32(S3), S120-S141
NKF Taskforce on CV Disease
PD: Optimising Outcomes?
Effect of CAPD Blood Pressure Control
Months
% V
ari
ati
on F
rom
Base
line
Saldanha AJKD 1993; 21:184-188
Patients transferred from HD to PD (n = 67)
-15
-10
-5
0
5
10
15
20
0 1 2 3 4 5 6 7 8 9 10 11 12
Weight
Hematocrit
Blood Pressure
**********
***p<0.05
PD: Optimising Outcomes?
Modality and Cardiovascular Disease
33%
74%81%
4%
25%
41%
010
2030
405060
7080
90100
Hypertension Arrhythmias SevereArrhytmias
Perc
en
t o
f p
ati
en
ts HD (n=27)
CAPD (n=27)
Canziani MD, et al, Artificial Organs, 1995; 19:241-244
PD: Optimising Outcomes?
PD as the Initial Form of Renal Replacement Therapy
• Better initial survival
• Preserves residual renal function
• Effective blood pressure and volume control
• PD Transplant: reduced risk of early acute renal failure
• Reduced risk of being infected by a blood borne virus
• Delays the use of HD blood access sites
• Quality of life
PD: Optimising Outcomes?
Transplantation and the role of PD
• Graft function immediately after transplantation is important• 24% of PD patients have delayed graft function (DGF) vs. 50% of
HD patients*• Patients with delayed graft function have a 10% decreased graft
survival• Reduced need of post-transplantation dialysis • PD patients have lower usage of immunosuppressive medication*• PD patients suffer a lower incidence of late infections*
* Perez Fontan M, Perit Dial Int, 1996, 16: 48-54
PD: Optimising Outcomes?
Dialysis Modality and Delayed Graft Function
Group PD HDP
Value
% anuric in first 24 h 8.3 11.9<0.00
1% dialysis in first week
20.0 28.6<0.00
1% treated for rejection
12.0 12.9 0.20
% non-functioning graft at discharge
13.7 14.8 0.14
Bleyer et al. J Am Soc Nephrol 10:154-159, 1999
PD: Optimising Outcomes?
PD as the Initial Form of Renal Replacement Therapy
• Better initial survival
• Preserves residual renal function
• Effective blood pressure and volume control
• PD Transplant: reduced risk of early acute renal failure
• Reduced risk of being infected by a blood borne virus
• Delays the use of HD blood access sites
• Quality of life
• Cheaper
PD: Optimising Outcomes?
Hepatitis B & C
02468
101214161820
Hepatitis B Hepatitis C
HD
PD
• 309 patients• Brazil• High background
prevalence of Hepatitis B & C
• Seroconversion partly related to blood transfusion (p=0.05)S
ero
con
vers
ion
(%
/yr)
P<0.001 P<0.02
Cendoroglo Neto NDT 10:240-46, 1995
PD: Optimising Outcomes?
Modality and Hepatitis C
7%
13%16%
19%
25%
44%
50%
31%
47%
20%
15%
5%
12%8%
0%2% 2%
5%
0%
10%
20%
30%
40%
50%
60%
Pe
rce
nt
of
pa
tie
nts
HD
PD
Pereira B. Kidney Int, 1997; 51:981-999
PD: Optimising Outcomes?
Why lower risk of HCV in PD?
• Lower requirement for blood transfusion than HD patients
• The absence of a vascular access site and extracorporeal blood circuit reduces the risk for parenteral exposure to the virus
• PD is a home therapy and it offers a more isolated environment
Pereira KI 1997; 51:981-999
PD: Optimising Outcomes?
PD as the Initial Form of Renal Replacement Therapy
• Better initial survival
• Preserves residual renal function
• Effective blood pressure and volume control
• PD Transplant: reduced risk of early acute renal failure
• Reduced risk of being infected by a blood borne virus
• Delays the use of HD blood access sites
• Quality of life
PD: Optimising Outcomes?
Total lifespan of vascular access
• Creation and maintenance of adequate vascular access remains a major problem in HD
• ESRD patients have compromised cardiovascular systems
• Any strategy that can augment the total lifespan of vascular access is of value
• Additional time is “won” by starting PD
PD: Optimising Outcomes?
Modality and EPO - Japan
0
10
20
30
40
50
Notused
1 - 1499 1500 -2999
3000 -4499
4500 -5999
6000 -8999
9000 +
rHuEPO dose (units/week)
Per
cen
t o
f p
atie
nts Hemodialysis
Peritoneal Dialysis
Shinzato T, et al, Kidney Int, 1999; 5:700-712
PD: Optimising Outcomes?
Modality and EPO - Europe
5,790 Units
7,370 Units
0
2,000
4,000
6,000
8,000
Hemodialysis (n=157) Peritoneal Dialysis (n=126)
rHuE
po d
ose
(uni
ts/w
eek)
House AA, et al, Nephrol Dial Transplant, 1998; 13:1763-1769
PD: Optimising Outcomes?
Modality and Transfusions
Parameter HD (n=157)
PD (n=126)
P value
Hemoglobin (g/dl) 10.47 10.71 0.45
Serum ferritin (g/dl) 258.7 253.8 0.77
Transferrin saturation (%) 28.5 28.1 0.94
Mean number of transfusions 4.59 2.17 0.01
% of patients receiving transfusion 52.9% 40.9% 0.01
House AA, et al, Nephrol Dial Transplant, 1998; 13:1763-1769
PD: Optimising Outcomes?
What is the Role of PD in Optimising ESRD Patient Outcomes?
• Influenced by:– Availability of modality options– Profile of co-morbidities– Patient choice and self-care motivation– Physician experience and knowledge– Outcome evidence
PD: Optimising Outcomes?
Following an integrated strategy of
dialysis that uses PD as an initial
therapy then HD may improve total
patient survival and preserve societal
resources which could be reallocated
to treat more of the continuously
increasing population of ESRD
patients.
Conclusion
Dratwa 1999