chapter 12 peritoneal dialysis

CHAPTER 12Peritoneal Dialysis

Sunita Bavanandan

Lily Mushahar

Anita Bhajan Manocha

Source: 20th MDTR Report 2012, NRR

Table 12.1.1: Peritoneal dialysis regimes, 1997-2012

PD regime2003 2004 2005 2006 2007

n % n % n % n % n %

Standard CAPD 1192 96.1 1266 96.8 1303 93.2 1397 90 1547 85.7

DAPD 34 3 39 2.8 45 3.2 67 4.3 115 6.4

Automated PD/ CCPD 5 0.9 12 0.4 50 3.6 88 5.7 144 8

TOTAL 1231 100 1317 100 1398 100 1552 100 1806 100

PD regime2008 2009 2010 2011 2012

n % n % n % n % n %

Standard CAPD 1717 82.4 1847 83.5 1973 83.6 2079 79.7 2320 80

DAPD 121 5.8 119 5.4 91 3.9 117 4.5 140 4.8

Automated PD/ CCPD 245 11.8 246 11.1 296 12.5 414 15.9 439 15.1

TOTAL 2083 100 2212 100 2360 100 2610 100 2899 100


Table 12.1.2: PD System, 1997-2012

PD System2003 2004 2005 2006 2007

n % n % n % n % n %

Baxter disconnect 1048 88.8 1147 87 1286 92.1 1425 92 1675 93.5

Fresenius disconnect 154 11.2 145 12.8 111 7.9 119 7.7 116 6.5

Others 3 0 0 0.2 0 0 5 0.3 0 0

TOTAL 1205 100 1292 100 1397 100 1549 100 1791 100

PD System 2008 2009 2010 2011 2012

n % n % n % n % n %

Baxter disconnect 1955 93.9 2013 92.1 2126 90.7 2230 85.8 2325 80.1

Fresenius disconnect 124 6 173 7.9 218 9.3 367 14.1 578 19.9

Others 4 0.2 0 0 1 0 1 0 1 0

TOTAL 2083 100 2186 100 2345 100 2598 100 2904 100


Table 12.1.3a: CAPD Number of Exchanges per day, 1997-2012

Number of exchanges/ day

2003 2004 2005 2006 2007

n % n % n % n % n %

2 3 0.5 6 0 3 0.2 3 0.2 2 0.1

3 14 1 12 1.2 20 1.5 52 3.7 29 1.9

4 1104 94.8 1185 95.9 1234 95.1 1296 93.2 1456 95.8

5 30 3.8 47 2.9 40 3.1 39 2.8 33 2.2

TOTAL 1151 100 1250 100 1297 100 1390 100 1520 100

Number of exchanges/ day

2008 2009 2010 2011 2012

n % n % n % n % n %

2 3 0.2 2 0.1 7 0.4 1 0 10 0.4

3 47 2.8 79 4.4 125 6.4 113 5.5 139 6.1

4 1611 94.4 1676 92.3 1778 91.1 1874 91.3 2064 90.2

5 46 2.7 59 3.2 42 2.2 65 3.2 75 3.3

TOTAL 1707 100 1816 100 1952 100 2053 100 2288 100


Table 12.1.3b: APD dwell volumes per day, 1997-2012

Dwell volumes/ day

2003 2004 2005 2006 2007

n % n % n % n % n %

8 0 0 0 0 9 47.4 6 12.5 11 10.5

10 1 100 4 100 7 36.8 32 66.7 83 79

12 0 0 0 0 3 15.8 10 20.8 10 9.5

14 0 0 0 0 0 0 0 0 0 0

16 0 0 0 0 0 0 0 0 1 1

TOTAL 1 100 4 100 19 100 48 100 105 100

Dwell volumes/ day

2008 2009 2010 2011 2012

n % n % n % n % n %

8 4 2.2 7 5.1 11 14.5 9 3.7 18 12.3

10 164 92.1 119 87.5 56 73.7 222 90.6 108 74

12 10 5.6 8 5.9 8 10.5 11 4.5 17 11.6

14 0 0 0 0 0 0 0 0 0 0

16 0 0 2 1.5 1 1.3 3 1.2 3 2.1

TOTAL 178 100 136 100 76 100 245 100 146 100


Table 12.2.1: Distribution of delivered Kt/V, PD patients 2003-2012

YearNumber of

PatientsMean SD Median LQ UQ

% patients ≥ 1.7 per week

2003 763 2.1 0.5 2.1 1.8 2.5 83

2004 1038 2.1 0.5 2.1 1.8 2.4 85

2005 1092 2.1 0.5 2.1 1.8 2.4 83

2006 1266 2.1 0.5 2.1 1.8 2.4 84

2007 1412 2.1 0.5 2.1 1.8 2.4 83

2008 1679 2.1 0.5 2 1.8 2.4 82

2009 1837 2.1 0.5 2 1.8 2.4 81

2010 1913 2.1 0.5 2 1.7 2.3 79

2011 1787 2.1 0.5 2 1.8 2.3 79

2012 2335 2.1 0.5 2 1.8 2.3 79


Figure 12.2.1: Cumulative distribution of delivered Kt/V, PD patients 1997-2012


0

.25

.5

.75

1

Cum

ulat

ive

dist

ribu

tion

1 1.2 1.4 1.6 1.8 2 2.2 2.4 2.6 2.8 3 3.2KT/V

2012 2011 2010 20092008 2007 2006 20052004 2003

Table 12.2.2: Variation in proportion of patients with Kt/V 1.7 per week among PD centres, 1997-2012

YearNumber of

centresMin 5th Centile LQ Median UQ

95th Centile

Max

2003 14 0 0 75 82.5 88 91 91

2004 17 75 75 79 85 88 100 100

2005 18 56 56 75 85 89 96 96

2006 20 66 66 78 82.5 91.5 100 100

2007 21 25 69 78 85 89 93 93

2008 20 33 50.5 76.5 80 89 93.5 96

2009 21 48 63 76 83 89 97 100

2010 22 48 59 73 79 86 90 94

2011 24 61 64 70.5 78.5 82.5 90 91

2012 25 53 59 70 79 87 95 100


Figure 12.2.2: Variation in proportion of patients with Kt/V 1.7 per week among PD centres


0

10

20

30

40

50

60

70

80

90

100

% p

atie

nts

0 2 4 6 8 10 12 14 16 18 20 22 24Centre

(lower 95% CI, upper 95% CI)% with KT/V >=1.7 per week

Table 12.2.3: Peritoneal transport status by PET D/P creatinine at 4 hours, new PD patients 2004-2012


Table 12.2.4: Peritoneal Transport Status (PET) with dialysis vintage

Duration (Years)

<1 1-<2 2-<3 3-<4 4-<5

n % n % n % n % n %

Low 53 12 49 10 34 12 24 10 12 8

Low average 190 43 173 36 116 40 88 37 74 48

High average 157 35 193 41 112 39 103 43 47 31

High 47 11 60 13 28 10 23 10 20 13

TOTAL 447 100 475 100 290 100 238 100 153 100

Duration (Years)

5-<6 6-<7 7-<8 8-<9 9-<10 10 or more

n % n % n % n % n % n %

Low 6 6 9 13 3 6 4 12 1 3 4 10

Low average 51 49 26 39 21 45 10 29 10 32 9 21

High average 37 35 26 39 19 40 19 56 19 61 20 48

High 11 10 6 9 4 9 1 3 1 3 9 21

TOTAL 105 100 67 100 47 100 34 100 31 100 42 100


Table 12.3.1(a): Unadjusted technique survival by age (uncensored for death and transplant), 1997-2012


Figure 12.3.1(a): Unadjusted technique survival by age (uncensored for death and transplant), 1997-2012


Age>=65Age 55-64Age 45-54Age 35-44Age 25-34Age 15-24Age 1-14

0.00

0.20

0.40

0.60

0.80

1.00

Cum

ula

tive

surv

ival

0 24 48 72 96 120 144 168 192 216 240Duration in months

Kaplan-Meier survival estimates, by Age

Table 12.3.1(b): Unadjusted technique survival by age (censored for death and transplant), 1997-2012


Figure 12.3.1(b): Unadjusted technique survival by age (censored for death and transplant), 1997-2012


Age>=65

Age 55-64

Age 45-54Age 35-44Age 25-34Age 15-24

Age 1-14

0.00

0.20

0.40

0.60

0.80

1.00

Cum

ulat

ive

surv

ival


Kaplan-Meier survival estimates, by Age

Table 12.3.2(a): Unadjusted technique survival by gender (uncensored for death and transplant), 1997-2012

Gender Interval (months)

Male Female

n % survival SE n % survival SE

0 4014 100 3906 100

6 3395 90 0 3315 90 0

12 2753 79 1 2755 80 1

24 1798 60 1 1895 63 1

36 1181 44 1 1300 49 1

48 741 32 1 868 38 1

60 468 24 1 608 31 1

72 305 18 1 412 24 1

84 183 13 1 275 19 1

96 111 9 1 179 14 1

108 69 7 1 119 12 1

120 37 5 1 70 9 1


Figure 12.3.2(a): Unadjusted technique survival by gender (uncensored for death and transplant), 1997-2012


Male

Female

0.00

0.25

0.50

0.75

1.00

Cum

ulat

ive

surv

ival


Kaplan-Meier survival estimates, by sex

Table 12.3.2(b): Unadjusted technique survival by gender (censored for death and transplant), 1997-2012

Gender Interval (months)

Male Female


0 4014 100 3906 100

6 3395 97 0 3315 97 0

12 2753 93 0 2755 94 0

24 1798 85 1 1895 87 1

36 1181 78 1 1300 79 1

48 741 71 1 868 73 1

60 468 63 1 608 68 1

72 305 57 1 412 64 1

84 183 50 2 275 58 2

96 111 46 2 179 52 2

108 69 42 2 119 49 2

120 37 34 3 70 43 2


Figure 12.3.2(b): Unadjusted technique survival by gender (censored for death and transplant), 1997-2012


Male

Female

0.00

0.25

0.50

0.75

1.00

Cum

ulat

ive

surv

ival


Kaplan-Meier survival estimates, by sex

Table 12.3.3(a): Unadjusted technique survival by diabetes status (uncensored for death and transplant), 1997-2012

Diabetes statusInterval (month)

Non-diabetic Diabetic


0 4729 100 3191 100

6 4035 92 0 2675 88 1

12 3369 83 1 2139 75 1

24 2351 68 1 1342 52 1

36 1688 56 1 790 33 1

48 1175 45 1 432 22 1

60 845 37 1 231 14 1

72 598 30 1 119 9 1

84 395 23 1 63 5 1

96 259 17 1 33 3 1

108 173 14 1 15 2 0

120 101 11 1 6 1 0


Figure 12.3.3(a): Unadjusted technique survival by Diabetes status (uncensored for death and transplant), 1997-2012


Diabetic

Non-diabetic

0.00

0.25

0.50

0.75

1.00

Cum

ulat

ive

surv

ival


Kaplan-Meier survival estimates, by Diabetes

Table 12.3.3(b): Unadjusted technique survival by diabetes status (censored for death and transplant), 1997-2012

Diabetes statusInterval (month)

Non- diabetes Diabetic


0 4729 100 3191 100

6 4035 97 0 2675 97 0

12 3369 93 0 2139 93 0

24 2351 86 1 1342 85 1

36 1688 79 1 790 77 1

48 1175 72 1 432 72 1

60 845 66 1 231 67 2

72 598 61 1 119 62 2

84 395 54 1 63 57 3

96 259 48 1 33 54 3

108 173 45 2 15 48 5

120 101 38 2 6 43 7


Figure 12.3.3(b): Unadjusted technique survival by diabetes status (censored for death and transplant), 1997-2012


Diabetic

Non-diabetic

0.00

0.25

0.50

0.75

1.00

Cum

ulat

ive

surv

ival


Kaplan-Meier survival estimates, by Diabetes

Table 12.3.4: Unadjusted technique survival by Kt/V, 1997-2012

Kt/V Interval (months)

<1.7 1.7-2.0 >2.0

n % Survival SE n % Survival SE n % Survival SE

0 2796 100 3975 100 8131 100

6 2713 98 0 3877 98 0 7963 99 0

12 2528 94 0 3666 95 0 7514 96 0

24 2104 84 1 3162 87 1 6393 87 0

36 1663 71 1 2625 76 1 5171 77 0

48 1228 59 1 2038 65 1 3996 66 1

60 858 47 1 1515 54 1 3093 57 1

72 616 38 1 1150 47 1 2305 50 1

84 415 29 1 779 37 1 1629 42 1

96 309 25 1 503 29 1 1190 35 1

108 202 20 1 345 23 1 846 30 1

120 135 18 1 205 18 1 481 24 1


Figure 12.3.4: Unadjusted technique survival by Kt/V,1997-2012


Kt/V >2.0Kt/V 1.7-2.0Kt/V <1.7

0.00

0.25

0.50

0.75

1.00C

umul

ativ

e su

rviv

al

0 24 48 72 96 120 144 168Duration in months

Kaplan-Meier survival estimates, by KTV

Table 12.3.5: Adjusted hazard ratio for change of modality, 1997-2012


Table 12.3.6: Reasons for drop-out from PD program, 2003-2012


Table 12.3.7: Drop-out rate from PD program with time on treatment, 2003-2012


Table 12.3.8: Time on PD (1997-2012)


Table 12.4.1 Variation in peritonitis rate (patient-month/episode) among PD centres, 1997-2012

YearNumber of

centresMin 5th Centile LQ Median UQ 95th Centile Max

1997 9 6 6 13.5 16.1 23.2 30 30

1998 9 0 0 17.7 23.5 29.1 54.9 54.9

1999 9 14.3 14.3 16.3 19.3 21 31.5 31.5

2000 11 11.7 11.7 17.4 23.2 30.6 71.4 71.4

2001 11 10.8 10.8 19.9 23.6 41.4 60.3 60.3

2002 11 12.6 12.6 17.9 32.7 44.4 219.2 219.2

2003 13 18.2 18.2 21.3 32.9 39.6 312.1 312.1

2004 15 0 0 23.6 32.9 36.6 41.5 41.5

2005 15 18 18 26.3 35.8 43 58 58

2006 21 14.8 18.5 27 37.9 49.8 65.2 97.7

2007 23 12 12.9 31.2 42.1 55.3 66.9 106.7

2008 25 12 13 30 40.4 58.7 105.5 114.6

2009 25 14 17.6 29.5 38.2 55.7 117.7 246.1

2010 26 10.8 19.3 28.1 36 52.3 72.2 84.9

2011 28 8.9 12 33.8 46 63.5 103.9 260.1

2012 27 25.5 34.8 44.3 53.8 73.5 170 249.1


Figure 12.4.1 Variation in peritonitis rate among PD centres, 2012


0

200

400

600

800

1000

Rat

e, p

t-m

onth

/epi

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28Centre

(lower 95% CI, upper 95% CI)Peritonitis rate

Table 12.4.2: Causative organism in PD peritonitis, 2003-2012


Figure12.4.2 Causative organism in PD peritonitis, 2001-2012

0

50

100

150

200

250

300

350

400

Frequency

'01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12

Staph. Aureus Staph coagulase neg.

Other gram positive Pseudomonas

E.Coli Polymicrobial

Fungal Mycobacterium

Culture negative


Figure 12.4.3(a): Outcome of peritonitis by causative organism, 2012

63.49%20.44%

16.07%

Resolved Not resolved, catheter removedDeath

Outcome of peritonitis in 2012


Table 12.4.3(a): Outcome of peritonitis by causative organism, 1993-2002

Causative Organism ResolvedNot resolved,

catheter removed

Death Total

n % n % n % n %

(A) Gram Positives

Staph. Aureus 150 69 23 11 44 20 217 100

Staph Coagulase Neg. 135 78 11 6 26 15 172 100

Streptococcus 35 66 5 9 13 25 53 100

Others 11 58 2 11 6 32 19 100

(B) Gram Negatives

Pseudomonas 36 38 28 29 32 33 96 100

Acinetobacter 44 61 10 14 18 25 72 100

Klebsiella 30 45 15 22 22 33 67 100

Enterobacter 27 54 10 20 13 26 50 100

E.Coli 43 61 3 4 24 34 70 100

Others 15 56 3 11 9 33 27 100

(C) Polymicrobial 11 25 14 32 19 43 44 100

(D) Others

Fungal 5 5 44 43 54 52 103 100

Mycobacterium 6 27 6 27 10 45 22 100

Others 7 54 3 23 3 23 13 100

(E) No growth 555 71 94 12 133 17 782 100Source: 20th MDTR Report 2012, NRR

Figure 12.4.3(b): Outcome of peritonitis by causative organism, 1993-2002

0

20

40

60

80

100

Per

cen

t (%

)

Sta

ph.

Aur

eus

Sta

ph C

oagu

lase

Neg

.

Str

ep

Oth

ers

Pse

udo

mon

as

Aci

neto

bact

er

Kle

bsi

ella

Ent

ero

bact

er

E.C

oli

Oth

ers

Pol

ymic

robi

al

Fun

gal

Myc

obac

teriu

m

Oth

ers

No

gro

wth

Resolved Not resolved, catheter removed Death


Table 12.4.3(b): Outcome of peritonitis by causative organism, 2003-2012

Causative OrganismResolved

Not resolved, catheter removed

Death Total

n % n % n % n %

(A) Gram Positives

Staph. Aureus 386 67 92 16 97 17 575 100

Staph Coagulase Neg. 358 80 30 7 59 13 447 100

Strep 153 81 13 7 24 13 190 100

Others 82 78 10 10 13 12 105 100

(B) Gram Negatives

Pseudomonas 102 35 83 28 109 37 294 100

Acinetobacter 107 58 34 18 45 24 186 100

Klebsiella 126 57 40 18 56 25 222 100

Enterobacter 51 58 11 13 26 30 88 100

E.Coli 222 62 45 13 93 26 360 100

Others 42 55 21 28 13 17 76 100

(C) Polymicrobial 10 32 6 19 15 48 31 100

(D) Others

Fungal 10 6 53 31 107 63 170 100

Mycobacterium 2 7 8 29 18 64 28 100

Others 108 62 29 17 38 22 175 100

(E) No growth 929 68 166 12 268 20 1363 100


Figure 12.4.3(c): Outcome of peritonitis by causative organism, 2003-2012


0

20

40

60

80

100

Per

cent

(%

)

Sta

ph. A

ureu

s

Sta

ph C

oagu

lase

Neg

.

Str

ep

Oth

ers

Pse

udom

onas

Aci

neto

bact

er

Kle

bsie

lla

Ent

erob

acte

r

E.C

oli

Oth

ers

Pol

ymic

robi

al

Fun

gal

Myc

obac

teriu

m

Oth

ers

No

grow

th


Figure 12.4.3(d): Comparing outcome of peritonitis by causative organism in 1993-2002 vs 2003-2012

0

20

40

60

80

100

Pe

rce

nt

(%)

Sta

ph

. A

ure

us

Sta

ph

Co

ag

ula

se N

eg

.

Str

ep

Oth

ers

Pse

ud

om

on

as

Aci

ne

tob

act

er

Kle

bsi

ella

En

tero

ba

cte

r

E.C

oli

Oth

ers

Po

lym

icro

bia

l

Fu

ng

al

Myc

ob

act

eriu

m

Oth

ers

No

gro

wth

19

93

-02

20

03

-12

19

93

-02

20

03

-12

19

93

-02

20

03

-12

19

93

-02

20

03

-12

19

93

-02

20

03

-12

19

93

-02

20

03

-12

19

93

-02

20

03

-12

19

93

-02

20

03

-12

19

93

-02

20

03

-12

19

93

-02

20

03

-12

19

93

-02

20

03

-12

19

93

-02

20

03

-12

19

93

-02

20

03

-12

19

93

-02

20

03

-12

19

93

-02

20

03

-12



Table 12.4.4: Risk factors influencing peritonitis rate, 1993-2012


chapter 12 peritoneal dialysis

Documents

mdtr report

pd centres source

new pd patients

pd ccpd50

pd ccpd24511

unadjusted technique

proportion of patients

age uncensored