what is the role of peritoneal dialysis in optimising esrd patient outcomes?

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


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


Modality Selection and DistributionWhere Do We Want To Be?


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


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)


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.


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 ?


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


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


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


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 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


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


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


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



• 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


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)


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


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


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


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.


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



• 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


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


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


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









• Quality of life


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


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









• Quality of life

• Cheaper


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


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


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









• Quality of life


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


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


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


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


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


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

what is the role of peritoneal dialysis in optimising esrd patient outcomes?

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patient survival

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role of peritoneal dialysis

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