MO813ANALYSING TRANSITIONS IN THE INTEGRATED MODEL OF RENAL REPLACEMENT THERAPY IN A REGIONAL HEALTH SYSTEM

Abstract

Abstract Background and Aims Every year 83,000 Europeans and 6,500 Spanish CKD patients require dialysis or transplantation. The choice of renal replacement therapy (RRT) is an important decision that determines the quality of life and survival. A single therapy option might not be adequate across a patient’s entire lifespan and a majority of patients change from one RRT modality to another to adapt RRT to clinical and psychosocial needs. Transitions should be considered as an expected progression in the patient’s treatment options. In these circumstances, there are new questions about the best sequence of techniques. Method This observational study examined a cohort of all incident patients from the Madrid Registry of Renal Patients (REMER), who initiated RRT between January 2008 and December of 2018. This study used the proportional hazards models and competitive risk models to examine the impact of transitions between RRT modalities on survival. We performed an intention-to-treat (ITT) analysis, according to the initial RRT chosen and an as treated (AT) analysis, by RRT received (Only HD, Only PD, PD then HD or HD then PD). Results A total of 8,971 patients started RRT during this period in Madrid (6.6 Million population): 7,207 on hemodialysis (HD), 1,401 on peritoneal dialysis (PD) and 363 received a pre-emptive kidney transplantation (KTX). Incident HD-patients were older and had more comorbidities. They presented higher mortality (HD group 40.9% vs PD group 22.8% vs 8.3% KTX group, p <0.001) and less access to a transplant (HD group 30.4% vs DP group 51.6%; p <0.001). Transitions between dialysis techniques define different groups of patients with different clinical outcomes. Those who change from HD to PD do it earlier (66% in less than 6 months), are younger and behave like those treated only with PD. Those who change from PD to HD do so later (1.5 years on average), are older (61.6 vs 53.5 years) and present higher mortality and less access to kidney transplantation than the group who initiates in HD and transfer to PD. Survival analysis by competitive risks is essential for integrated RRT models, especially in groups such as PD patients, where 58.6% of the patients were considered as lost follow-up (received a KTX after during the first 2.5 years on PD). This analysis reflects how patients who change dialysis modality share more characteristics with the second technique than the original one. Conclusion Our data suggest that transitions between RRT-techniques describes different patients, who associate different risks, and should be analyzed in an integrated manner to define improvement actions. This approach should be incorporated into the analysis and repports of renal registries.