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Renal M
ed
icin
e
David JohnsonPrincess Alexandra Hospital
Brisbane, Australia
A Comparison of APD A Comparison of APD vs CAPD on Patient vs CAPD on Patient
OutcomesOutcomes
Badve S, Hawley CM, Mudge DW,Rosman JB, Brown FG, Johnson DW
?CAPD APD
APD vs CAPD Use in Australia
0200400600800
100012001400160018002000
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
CAPDAPD
5% 7% 11%14%
Num
ber
22%27%
33%39% 41% 43%
APD Use: USA vs Aust vs UK
0
10
20
30
40
50
60
70
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
Per
cent
of
PD
Pat
ient
s
USAAustraliaUK
Traditional APD Indications
Enhance small solute clearances Enhance ultrafiltration (esp high transport) Social reasons
– Employment
– School
– Care of elderly/debilitated patients
Mechanical problems– Hernias, leaks, back pain, body image
Reduce peritonitis rates
Rabindranath NDT (In press)
N=139
Ultrafiltration: APD vs CAPD
0
200
400
600
800
1000
1200
1400
1600
1800U
F (
ml/
da
y)
P=NS
N=25
Bro et al Perit Dial Int 19:526-33,1999
CAPD APD
QOL: APD vs CAPD
Scale Scores Parameter
APD (n=12)
CAPD (n=13)
P Value
Social Time 3.21.2 1.20.5 0.0005
Physical discomfort 1.91.0 2.21.3 NS
Emotional discomfort 1.81.0 2.21.4 NS
Anorexia 2.81.3 2.90.6 NS
Sleep Problems 2.30.9 1.81.3 NS
Bro et al Perit Dial Int 19:526-33,1999
RRF Loss: APD vs CAPD
0
1
2
3
4
5
6
7
0 6 12
Follow-up (months)
Res
idua
l Cl C
r (m
l/min
)
CAPD APD
Hufnagel et al Nephrol Dial Transplant 14:1224-8, 1999
* ** p<0.05n=36
US Study
Survival Technique Survival
HR P HR P
Age 1.04 <0.0001 1.007 <0.0001
PD 1st 0.725 <0.0001 0.789 <0.0001
Diabetes 0.701 <0.0001 0.852 <0.0001
Centre 0.94 <0.0001
APD 0.845 <0.0001
Mujais and Story Kidney Int 70:S21-6, 2006
USA
Aim
To compare patient survival and death-censored technique survival in patients treated with APD vs CAPD using ANZDATA
Methods
All ANZ patients starting PD between April 1, 1999 and March 31, 2004
Complete follow-up 1° outcomes death and death-censored technique
failure Survival time calculated from date of
commencement of each PD episode to the date of death, transfer to hemodialysis, transplantation, loss of follow up, or March 31, 2004.
Statistics Kaplan-Meier and multivariate Cox proportional
hazards model analyses PD modality included as a time-dependent
covariate Analyses stratified according to initial or
subsequent episodes of PD Used a conditional risk set model for multiple
failure data Standard errors calculated using robust variance
estimation for the correlated data, clustered according to the centre of initial treatment
Baseline Characteristics
Characteristic All patients CAPD (APD never) APD ever Number of observations 10391 5067 (48.8%) 5324 (51.2%) Male gender a 5549 (53.4%) 2567 (50.7%) 2982 (56%) Age (years) a 58 ± 16 60 ± 14.5 56.1 ± 17.1
Racial origin a
Caucasians 7388 (71.1%) 3435 (67.8%) 3953 (74.3%) Aboriginal, Torres Strait Islander 557 (5.4%) 281 (5.6%) 276 (5.2%) MPI, Cook Islander, Samoan, Tongan 1364 (13.1%) 812 (16%) 552 (10.4%) Asian 922 (8.9%) 459 (9.1%) 463 (8.7%) Others 160 (1.6%) 80 (1.6%) 80 (1.5%)
Chronic lung disease 1360 (13.1%) 695 (13.7%) 665 (12.5%) Coronary artery disease a 3880 (37.3%) 2042 (40.3%) 1838 (34.5%) Peripheral vascular disease 2621 (25.2%) 1304 (25.7%) 1317 (24.7%) Cerebrovascular disease a 1449 (13.9%) 768 (15.2%) 681 (12.8%) Diabetes mellitus a 3832 (36.9%) 2073 (40.9%) 1759 (33%) Smoking status b Never 5065 (48.7%) 2410 (47.6%) 2655 (49.9%) Former 4027 (38.8%) 1993 (39.3%) 2034 (38.2%) Current 1299 (12.5%) 664 (13.1%) 635 (11.9%) Body mass index (kg/m2) a 26 ± 5.2 26.3 ± 5.2 25.7 ± 5.2
≤ 19.9 1038 (10%) 427 (8.4%) 611 (11.5%) 20-24.9 3830 (36.9%) 1818 (35.9%) 2012 (37.8%) 25-29.9 3420 (32.9%) 1718 (33.9%) 1702 (32%) ≥ 30 2094 (20.2%) 1102 (21.8%) 992 (18.7%) D-P Cr 4h a 0.69 ± 0.12 0.69 ± 0.12 0.70 ± 0.12 Peritoneal membrane transport status a Low 510 (4.9%) 263 (5.2%) 247 (4.6%) Low average 2946 (28.4%) 1550 (30.6%) 1396 (26.2%) High average 5200 (50%) 2485 (49%) 2715 (51%)
Patient Survival0.
000.
250.
500.
751.
00
0 1 2 3 4 5Years
CAPD APD
Patient survival by PD modality
Badve et al Kidney Int (In press)
N=4128
AHR 1.03 (95% CI 0.86-1.24) p=0.72
Death-Censored Technique Survival
0.00
0.25
0.50
0.75
1.00
0 1 2 3 4 5Years
CAPD APD
Death-censored technique survival by PD modality
N=4128
AHR 1.08 (95% CI 0.91-1.27) p=0.38
Badve et al Kidney Int (In press)
Death-Censored Technique Survival after 1st Failure Occurrence
0.00
0.25
0.50
0.75
1.00
0 1 2 3 4 5Years
CAPD bef ore the 1st f ailure APD before the 1st f ailure
CAPD af ter the 1st f ailure APD af ter the 1st f ailure
Kaplan-Meier Graph for Death Censored Technique survival
Badve et al Kidney Int (In press)
Propensity Score: Survival
Model HR 95%CI P
Unadjusted 0.92 0.77 – 1.09 0.336
Adjusted 1.03 0.86 – 1.24 0.723
Adjusted+PS 0.84 0.68 – 1.03 0.09
Badve et al Kidney Int (In press)
PS: Death-Censored Technique Survival
Model HR 95%CI P
Unadjusted 1.09 0.92 – 1.30 0.319
Adjusted 1.08 0.91 – 1.27 0.381
Adjusted+PS 1.07 0.91 – 1.27 0.381
Badve et al Kidney Int (In press)
Conclusions
APD results in similar patient survival and technique success rates compared to CAPD in 4,128 ANZ PD patients followed over 6,982 person-years
There is currently no strong clinical evidence, except for lifestyle considerations, for favouring APD over CAPD