perspectives in peritoneal dialysis

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Updated Nephrology Trainee Seminar Presentation on the Qualitative Aspects of Peritoneal Dialysis - September 2014

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  • 1. Perspectives on Peritoneal Dialysis
  • 2. 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
  • 3. International Variation in Modality Rates of PD in developing world increasing 8- 10%/annum Developing countries noted prevalence increase by 300% past 10 years.
  • 4. International Variation in PD
  • 5. Prevalent Patients in UK by RRT Modality (1997-2010)
  • 6. Where does PD fit into a Renal Replacement Programme? Low Clearance Peritoneal Dialysis Haemo-dialysis Transplantation Conservative Therapy
  • 7. 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
  • 8. 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?
  • 9. Is there potential competition with other Home Dialysis Modalities? (Almost) Mutually Exclusive Demographics Age / Sex / Cause of ESRD Co-morbid Profile ESRD Vintage
  • 10. Why such variation in PD Therapy provision?
  • 11. 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
  • 12. 4. Socio-economic factors Structure of dialysis program Number of dialysis centres 5. Cultural factors Attitude towards chronic disease Attitude towards home therapy
  • 13. Peritoneal Dialysis vs. Haemodialysis
  • 14. 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
  • 15. 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
  • 16. 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)
  • 17. What about Residual Renal Function?
  • 18. Role of Residual Renal Function Residual 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: 10611070 Haemodialysis Shemin 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)
  • 19. Peritoneal Dialysis in Acute Kidney Injury Do we have enough evidence to use it?
  • 20. 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
  • 21. 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)
  • 22. Delivering PD for AKI in Developing Countries Helping deliver PD in Sub-saharan Africa Papers published on work in Tanzania / Nigeria / Ghana showing respectable outcomes in small cohorts (Kilonzo et al PDI 2012)
  • 23. Is acute unplanned PD feasible and safe?
  • 24. Potential Scenarios Low clearance patient wanting to start HD with an AVF GFR now 7ml/min, AVF hasnt 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
  • 25. 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
  • 26. 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
  • 27. 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.
  • 28. PD when all other access options are exhausted Aitken et al. JVA 2014 62 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%
  • 29. Peritoneal Dialysis as a Bridge to Transplantation
  • 30.