Death-censored Technique Failure Research Articles

Mesenteric elasticity assessed by shear wave elastography and its relationship with peritoneal function in peritoneal dialysis patients.

We evaluated the mesenteric elasticity in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) using shear wave elastography (SWE) and investigated its relationships with peritoneal function. Patients were recruited in our peritoneal dialysis (PD) centre between 15 July 2019 and 31 December 2021 and followed up to 31 March 2022. Twelve chronic kidney disease (CKD) patients and nineteen healthy people were included as controls. Correlation, linear regression and Cox regression analyses were applied. Of the 218 PD patients, 104 (47.8%) were male. Their mean age was 48.0±13.2years and the median PD duration was 59.0months [interquartile range (IQR) 17.0-105]. The median mesenteric SWE value was 8.15kPa (IQR 5.20-16.1). The mesenteric SWE values of patients with a PD duration of <3months [5.20kPa (IQR 3.10-7.60)] were not significantly different from those of CKD patients [4.35kPa (IQR 2.63-5.20), P=.17] and healthy controls [3.60kPa (IQR 2.90-5.10), P=.13] but were lower than those of patients with a PD duration of 3months-5years [6.40kPa (IQR 4.10-10.5), P<.001], 5-10years [11.9kPa (IQR 7.40-18.2), P<.001] and >10years [19.3kPa (IQR 11.7-27.3), P<.001]. Longer PD duration (β=0.58, P<.001), high effluent interleukin-6 (β=0.61, P=.001) and low effluent cancer antigen 125 (β=-0.34, P=.03) were independently associated with low mesenteric elasticity. The mesenteric SWE value was independently correlated with the dialysate:plasma creatinine ratio (β=0.39, P=.01) and negatively correlated with the total daily fluid volume removed (β=-0.17, P=.03). High mesenteric SWE values were an independent risk factor for death-censored technique failure [adjusted hazard ratio 4.14 (95% confidence interval 1.25-13.7), P=.02). SWE could be used to non-invasively characterize peritoneal textural changes, which were closely associated with changes in peritoneal function.

MO706: The Peritoneal Equilibration Test at the Start of Peritoneal Dialysis and Patient Outcome. Analysis in the Presence of Competing Events

Abstract BACKGROUND AND AIMS The success of peritoneal dialysis (PD) depends on the integrity of the peritoneal membrane. The most common peritoneal functional alteration is an impaired ultrafiltration caused by fast peritoneal solute transfer rate. This situation can be present at start of PD and compromise the durability of the membrane through the stay on PD. If the patient leaves PD for another reason, as in the case of a kidney transplant, it affects the probability of a membrane dysfunction appearance. It is known as a competitive event. The aim of this study was to determine whether baseline peritoneal transport status was a risk factor of mortality and technique failure in a cohort of Spanish PD patients using a statistical competing risk model. METHOD The multicenter retrospective cohort study included adult patients of the Levante Registry PD Work Group in Spain who started PD between February 1993 and June 2020. All patients needed to have a peritoneal equilibration test (PET) performed within the first 6 months after PD start. Patients were followed until technique failure, transplantation, renal function recovery, death, or until September 2020. Peritoneal transport status was considered both as a continuous (D/PCr4h) and as a categorical variable, according to the four groupings of D/PCr values defined by Twardoski. We analysed the effect of peritoneal transport over mortality, peritonitis and technique failure by a competing risk model. Kidney transplantation and renal function recovery were considered competing events. RESULTS A total of 4848 patients were enrolled. Baseline PET measurements were available in 2.307 (47.6%). The median follow-up time was 22.2 months (IQR 11.5–40.5). The main characteristics according to the peritoneal transport status are summarized in Table 1. When peritoneal membrane transport was analysed as a continuous variable, D/PCr was an independent risk factor of technique failure. The hazard ratio subdistribution for technique failure was 1.08 [(1.01; 1.16), P-value = 0.018] for every 0.1 increase in D/P Cr ratio. This effect disappeared when the use of icodextrin was included in the model. Baseline peritoneal transport was not associated with a higher mortality or peritonitis risk. CONCLUSION Basal peritoneal transport rate is an independent risk factor for death-censored technique failure in the Levante DP incident population. The use of icodextrin in these patients seems to mitigate this negative effect and may improve the outcomes in PD in patients with initial fast transport. Conventional methods for survival analysis ignoring the competing events may be inappropriate this cohort of patients.

Technique failure in peritoneal dialysis: Modifiable causes and patient-specific risk factors.

Technique survival is a core outcome for peritoneal dialysis (PD), according to Standardized Outcomes in Nephrology-Peritoneal Dialysis. This study aimed to identify modifiable causes and risk factors of technique failure in a large Dutch cohort using standardised definitions. Patients who participated in the retrospective Dutch nOcturnal and hoME dialysis Study To Improve Clinical Outcomes cohort study and started PD between 2012 and 2016 were included and followed until 1 January 2017. The primary outcome was technique failure, defined as transfer to in-centre haemodialysis for ≥ 30 days or death. Death-censored technique failure was analysed as secondary outcome. Cox regression models and competing risk models were used to assess the association between potential risk factors and technique failure. A total of 695 patients were included, of whom 318 experienced technique failure during follow-up. Technique failure rate in the first year was 29%, while the death-censored technique failure rate was 23%. Infections were the most common modifiable cause for technique failure, accounting for 20% of all causes during the entire follow-up. Leakage and catheter problems were important causes within the first 6 months of PD treatment (both accounting for 15%). APD use was associated with a lower risk of technique failure (hazard ratio 0.66, 95% confidence interval 0.53-0.83). Infections, leakage and catheter problems were important modifiable causes for technique failure. As the first-year death-censored technique failure rate remains high, future studies should focus on infection prevention and catheter access to improve technique survival.

Early technique failure in peritoneal dialysis patients in a multi-ethnic Asian country.

Early technique failure is a serious complication for peritoneal dialysis (PD) patients. The study aimed to examine the incidence, causes, and risk factors associated with early technique failure. METHODS: This retrospective study included all incident PD patients in a hospital in Singapore from 2013 to 2017. The primary outcome was early technique failure, which was defined as transfer to hemodialysis for ≥ 30days or death, within the first year of PD initiation. Secondary outcomes were death, technique failure due to PD infection, and death-censored technique failure. Overall, 517 patients were included in the study. Of these, 98 patients (19.0%) developed early technique failure. The common causes of early technique failure were death (41.8%) and infection (40.8%). Peripheral vascular disease was significantly associated witha higher hazard of early technique failure [hazard ratio (HR) 1.95, 95% confidence interval (CI) 1.04-3.63] and death (HR 3.75, 95% CI 1.71-8.21), whilst glomerulonephritis as a cause of end-stage kidney disease (compared with hypertension) was associated witha lower hazard of early technique failure (HR 0.38, 95% CI 0.18-0.77) and death (HR 0.08, 95% CI 0.02-0.37). Male gender was associated with early technique failure due to PD infection (HR 2.55, 95% CI 1.32-4.95). No specific factor was associated with death-censored early technique failure. Technique failure in the first year of PD initiation occurs in one-fifth of PD patients and is associated with peripheral vascular disease and cause of end-stage kidney disease.

Higher Eosinophils Predict Death-Censored Technique Failure in Peritoneal Dialysis Patients

Introduction: Eosinophilia (eosinophil fraction of leukocytes >5%), an indicative parameter for bioincompatibility in various circumstances, is well established in hemodialysis. However, change in eosinophil count (EOC) and its association with death-censored technique failure among peritoneal dialysis (PD) patients remain unclear. Methods: We compared eosinophils before and after PD initiation among 1,432 eligible continuous ambulatory PD patients regularly followed up in our PD center during 2007–2018. Risk factors of early-stage eosinophilia were examined by the logistic regression test. The relationship of early-stage eosinophilia and EOC with death-censored technique failure was examined using the Cox proportional hazards model for overall patients and for men and women separately. Results: After PD initiation, the EOC and percentage of patients with eosinophilia were significantly increased compared with baseline. Being male (odds ratio [OR]: 2.26; 95% confidence interval [CI]: 1.55–3.31; p < 0.001) and higher EOC at baseline (100 cells/μL increase, OR: 1.62; 95% CI: 1.45–1.82; p < 0.001) were risk factors of early-stage eosinophilia after PD initiation. During follow-up, 204 death-censored technique failures were recorded. In fully adjusted models, each with 100 cells/μL increase in EOC, the adjusted hazard ratios (HRs) of technique failure were 1.11 (95% CI: 1.03–1.20; p = 0.009) in the whole cohort, 1.29 (95% CI: 1.10–1.51; p = 0.002) in women, and 1.07 (95% CI: 0.97–1.17; p = 0.196) in men. Eosinophilia was significantly associated with the risk of technique failure for women (HR: 2.24; 95% CI: 1.07–4.70; p = 0.033), which was especially significant for women aged <55 years (HR: 7.61; 95% CI: 1.88–30.90; p = 0.005). Conclusion: EOC was increased significantly after PD initiation, and increased numbers of eosinophils were associated with higher death-censored technique failure in PD patients, especially women.

Ten-year survival of patients treated with peritoneal dialysis: A prospective observational cohort study.

Few studies evaluated over 5-year outcomes of dialysis patients. This study examined 10-year all-cause mortality and death-censored technique failure in a cohort of incident peritoneal dialysis (PD) individuals. Five hundred and thirty-three incident PD individuals from 2006 to 2008 were prospectively followed up for more than 10 years until 2018. Clinical characteristics at PD initiation were collected. The primary outcome was all-cause mortality, and the secondary outcome was death-censored technique failure. Cox hazards models were fit using clinical characteristics at PD initiation. The mean age starting PD for these participants was 48 ± 16 years; 130 (24%) patients had diabetic nephropathy. During follow-up, 208 patients died, and 84 patients experienced technique failures. The 1, 3, 5, and 10 years' survival rates for incident PD patients were 93%, 81%, 64%, and 36%, respectively, and the technical survival rates were 98%, 93%, 85%, and 62%, respectively. Mortality risk was much higher after 3 years on PD. The peritonitis rate was 0.19 episodes per patient-year, and 7 (1.3%) patients had encapsulating peritoneal sclerosis (EPS) giving an incidence rate of 3.1 of 1000 patient-years. The main causes of death were cardiovascular events (97 of 208, 47%), and technique failure was mainly due to peritonitis (41 of 84, 49%). Older age, higher Charlson comorbidity index, and lower level of education were strongly associated with mortality, and diabetic nephropathy was an independent risk factor for technique failure. The 10-year's survival and technique survival rates of incident PD patients were 36% and 62%. Long-term PD can be continued successfully with improved outcomes and low risk for EPS.

Incidence and risk factors of peritoneal dialysis-related peritonitis in elderly patients: A retrospective clinical study

This study was to analyze the incidence, risk factors, and clinical outcomes of peritonitis in elderly continuous ambulatory peritoneal dialysis (CAPD) patients. Incident patients undergone CAPD from 1 January 2006 to 30 June 2015 in our center were enrolled and divided into aged < 65 years and ≥ 65 years groups. Risk factors were evaluated using a logistic regression model, and outcome comparison was evaluated using a Cox proportional model. Among 1953 patients, 111(33.2%) in elderly (n = 334) and 470 (29.0%) in younger (n = 1619) developed at least one episode of peritonitis. Comparing with younger patients, elderly ones had a higher peritonitis rate (0.203 vs. 0.145 episodes/patient-year, p < 0.05). The multivariate Cox regression showed that advanced age (hazard ratio (HR) = 1.06, 95% confidence interval (CI) = 1.01-1.11, p = 0.015), assistant-assisted peritoneal dialysis (PD; HR = 2.64, 95% CI = 1.23-5.64, p = 0.012), higher body mass index (BMI; HR = 1.11, 95% CI = 1.02-1.20, p = 0.010), and low serum albumin level (HR = 0.94, 95% CI = 0.90-0.98, p = 0.004) were associated with increased peritonitis risk in elderly patients. Compared with younger ones with peritonitis, elderly patients had an approximately fourfold increased risk of peritonitis-related mortality (odd ratio (OR) = 3.57, 95% CI = 1.38-9.28, p = 0.009). During the cohort, peritonitis was the risk factor associated with technique failure (HR = 3.19, 95% CI = 2.33-4.39, p < 0.001) in younger patient but not in the elderly population (HR = 1.82, 95% CI = 0.84-3.94, p = 0.132). Elderly PD patients had higher prevalence for peritonitis and peritonitis-related mortality. Advanced age, assistant-assisted PD, a higher BMI, and lower serum albumin level were independently associated with the first episode of peritonitis in elderly patients. However, peritonitis was not the predictor of death-censored technique failure in elderly ones.

Association between causes of peritoneal dialysis technique failure and all-cause mortality

Technique failure is a frequent complication of peritoneal dialysis (PD), but the association between causes of death-censored technique failure and mortality remains unclear. Using Australian and New Zealand Dialysis and Transplant (ANZDATA) registry data, we examined the associations between technique failure causes and mortality in all incident PD patients who experienced technique failure between 1989–2014. Of 4663 patients, 2415 experienced technique failure attributed to infection, 883 to inadequate dialysis, 836 to mechanical failure and 529 to social reasons. Compared to infection, the adjusted hazard ratios (HR) for all-cause mortality in the first 2 years were 0.83 (95%CI 0.70–0.98) for inadequate dialysis, 0.78 (95%CI 0.66–0.93) for mechanical failure and 1.46 (95%CI 1.24–1.72) for social reasons. The estimates from the competing risk models were similar. There was an interaction between age and causes of technique failure (pinteraction < 0.001), such that the greatest premature mortality was observed in patients aged >60 years post social-related technique failure. There was no association between causes of technique failure and mortality beyond 2 years. In conclusion, infection and social-related technique failure are associated with premature mortality within 2 years post technique failure. Future studies examining the associations may help to improve outcomes in these patients.

Multicenter Registry Analysis of Center Characteristics Associated with Technique Failure in Patients on Incident Peritoneal Dialysis.

Technique failure is a major limitation of peritoneal dialysis. Our study aimed to identify center- and patient-level predictors of peritoneal dialysis technique failure. All patients on incident peritoneal dialysis in Australia from 2004 to 2014 were included in the study using data from the Australia and New Zealand Dialysis and Transplant Registry. Center- and patient-level characteristics associated with technique failure were evaluated using Cox shared frailty models. Death-censored technique failure and cause-specific technique failure were analyzed as secondary outcomes. The study included 9362 patients from 51 centers in Australia. The technique failure rate was 0.35 (95% confidence interval, 0.34 to 0.36) episodes per patient-year, with a sevenfold variation across centers that was mainly associated with center-level characteristics. Technique failure was significantly less likely in centers with larger proportions of patients treated with peritoneal dialysis (>29%; adjusted hazard ratio, 0.83; 95% confidence interval, 0.73 to 0.94) and more likely in smaller centers (<16 new patients per year; adjusted hazard ratio, 1.10; 95% confidence interval, 1.00 to 1.21) and centers with lower proportions of patients achieving target baseline serum phosphate levels (<40%; adjusted hazard ratio, 1.15; 95% confidence interval, 1.03 to 1.29). Similar results were observed for death-censored technique failure, except that center target phosphate achievement was not significantly associated. Technique failure due to infection, social reasons, mechanical causes, or death was variably associated with center size, proportion of patients on peritoneal dialysis, and/or target phosphate achievement, automated peritoneal dialysis exposure, icodextrin use, and antifungal use. The variation of hazards of technique failure across centers was reduced by 28% after adjusting for patient-specific factors and an additional 53% after adding center-specific factors. Technique failure varies widely across centers in Australia. A significant proportion of this variation is related to potentially modifiable center characteristics, including peritoneal dialysis center size, proportion of patients on peritoneal dialysis, and proportion of patients on peritoneal dialysis achieving target phosphate level.

Patient Survival and Technique Failure in Continuous Ambulatory Peritoneal Dialysis Patients with Prior Stroke.

♦ To investigate patient survival and technical failure of patients with prior stroke receiving continuous ambulatory peritoneal dialysis (CAPD) in Southern China. ♦ This was a retrospective study. All subjects were recruited from the peritoneal dialysis center in The First Affiliated Hospital of Sun Yat-sen University from 1 January 2006 to 31 December 2010. All eligible patients were assigned to stroke group and non-stroke group according to a history of stroke before receiving CAPD. The primary outcomes were all-cause mortality and death-censored technical failure. Cox regression was used to estimate risk factors of all-cause mortality and death-censored technique failure. ♦ Of the 1,068 recruited patients, 75 (7.0%) patients had a previous history of stroke. The all-cause mortality and death-censored technique failure were significantly higher in the stroke group compared with the non-stroke group, respectively (odds ratio [OR] 2.67, 95% confidence interval [CI] 1.59 - 4.46 and OR 2.52, 95% CI 1.19 - 5.34). Older age (changed by 10 years, hazard ratio [HR] 1.90, 95% CI 1.07 - 3.38), lower body mass index (BMI 18.5 - 23.9 vs < 18.5 kg/m(2) reference, HR 0.17, 95% CI 0.05 - 0.55) and time to the first episode of peritonitis (HR 0.93, 95% CI 0.89 - 0.96) were independently associated with increased risk of all-cause mortality in patients with prior stroke. In addition, time to the first episode of peritonitis was associated with decreased risk of death-censored technique failure (HR 0.91, 95% CI 0.84 - 0.99) in those with prior stroke. ♦ Continuous ambulatory peritoneal dialysis patients with prior stroke had high rates of all-cause mortality and technique failure compared with those without prior stroke. Older age, lower BMI, and time to the first episode of peritonitis were independent risk factors of all-cause mortality in patients with prior stroke.

Influence of Peritoneal Transport Characteristics on Nutritional Status and Clinical Outcome in Chinese Diabetic Nephropathy Patients on Peritoneal Dialysis

Background:High peritoneal transport status was previously thought to be a poor prognostic factor in peritoneal dialysis (PD) patients. However, its effect on diabetic nephropathy PD patients is unclear in consideration of the adverse impact of diabetes itself. The purpose of this study was to investigate the influence of peritoneal transport characteristics on nutritional status and clinical outcome in diabetic nephropathy patients on PD.Methods:One hundred and two diabetic nephropathy patients on PD were enrolled in this observational cohort study. According to the initial peritoneal equilibration test result, patients were divided into two groups: Higher transport group (HT, including high and high average transport) and lower transport group (LT, including low and low-average transport). Demographic characteristics, biochemical data, dialysis adequacy, and nutritional status were evaluated. Clinical outcomes were compared. Risk factors for death-censored technique failure and mortality were analyzed.Results:Compared with LT group (n = 37), serum albumin was significantly lower and the incidence of malnutrition by subjective global assessment was significantly higher in HT group (n = 65) (P < 0.05). Kaplan–Meier analyses showed that death-censored technique failure and mortality were significantly increased in HT group compared with that in LT group. On multivariate Cox analyses, higher peritoneal transport status and lower residual renal function (RRF) were independent predictors of death-censored technique failure when adjusted for serum albumin and total weekly urea clearance (Kt/V). Independent predictors of mortality were advanced age, anemia, hypoalbuminemia, and lower RRF, but not higher peritoneal transport status.Conclusions:Higher peritoneal transport status has an adverse influence on nutrition for diabetic nephropathy patients on PD. Higher peritoneal transport status is a significant independent risk factor for death-censored technique failure, but not for mortality in diabetic nephropathy patients on PD.

Effluent Free Radicals Are Associated with Residual Renal Function and Predict Technique Failure in Peritoneal Dialysis Patients

Residual renal function (RRF) is associated with low oxidative stress in peritoneal dialysis (PD). In the present study, we investigated the relationship between the impact of oxidative stress on RRF and patient outcomes during PD. Levels of free radicals (FRs) in effluent from the overnight dwell in 45 outpatients were determined by electron spin resonance spectrometry. The FR levels, clinical parameters, and the level of 8-hydroxy-2'-deoxyguanosine were evaluated at study start. The effects of effluent FR level on technique and patient survival were analyzed in a prospective cohort followed for 24 months. Levels of effluent FRs showed significant negative correlations with daily urine volume and residual renal Kt/V, and positive correlations with plasma β(2)-microglobulin and effluent 8-hydroxy-2'-deoxyguanosine. A highly significant difference in technique survival (p < 0.05), but not patient survival, was observed for patients grouped by effluent FR quartile. The effluent FR level was independently associated with technique failure after adjusting for patient age, history of cardiovascular disease, and presence of diabetes mellitus (p < 0.001). The level of effluent FRs was associated with death-censored technique failure in both univariate (p < 0.001) and multivariate (p < 0.01) hazard models. Compared with patients remaining on PD, those withdrawn from the modality had significantly higher levels of effluent FRs (p < 0.005). Elevated effluent FRs are associated with RRF and technique failure in stable PD patients. These findings highlight the importance of oxidative stress as an unfavorable prognostic factor in PD and emphasize that steps should be taken to minimize oxidative stress in these patients.

Compared with Younger Peritoneal Dialysis Patients, Elderly Patients have Similar Peritonitis-Free Survival and Lower Risk of Technique Failure, but Higher Risk of Peritonitis-Related Mortality

The number of elderly patients with end-stage kidney disease (ESKD) is increasing worldwide, but the proportion of elderly patients commencing peritoneal dialysis (PD) is falling. The reluctance of elderly ESKD patients to consider PD may be related to a perception that PD is associated with greater rates of complications. In the present study, we compared outcomes between younger and older PD patients. Using Australia and New Zealand Dialysis Registry data, all adult ESKD patients commencing PD between 1991 and 2007 were categorized into under 50, 50 - 64.9, and 65 years of age or older groups. Time to first peritonitis, death-censored technique failure, and peritonitis-associated and all-cause mortality were evaluated by multivariate Cox proportional hazards model analysis. Of the 12 932 PD patients included in the study, 3370 (26%) were under 50 years of age, 4386 (34%) were 50 - 64.9 years of age, and 5176 (40%) were 65 years of age or older. Compared with younger patients (<50 years), elderly patients (≥ 65 years) had a similar peritonitis-free survival and a lower risk of death-censored technique failure [hazard ratio (HR): 0.85; 95% confidence interval (CI): 0.79 to 0.93], but they had higher peritonitis-related (HR: 2.31; 95% CI: 1.68 to 3.18) and all-cause mortality (HR: 2.90; 95% CI: 2.60 to 3.23). Not unexpectedly, elderly patients have higher peritonitis-related and all-cause mortality, which is likely a consequence of a greater prevalence of comorbid disease. However, compared with younger patients, elderly patients have superior technique survival and similar peritonitis-free survival, suggesting that PD is a viable renal replacement therapy in this group of patients.

Peritoneal Small Solute Clearance is Nonlinearly Related to Patient Survival in the Australian and New Zealand Peritoneal Dialysis Patient Populations

The contribution of peritoneal small solute clearance per se to peritoneal dialysis (PD) patient outcomes remains uncertain. The aim of the present study was to determine whether baseline peritoneal small solute clearance predicted subsequent survival in Australian and New Zealand PD patients. The study included all adult patients in Australia and New Zealand that commenced PD between 1 April 2002 and 31 December 2005 and had a peritoneal Kt/V (pKt/V) measurement performed within 6 months of PD commencement. Time to death and death-censored technique failure were examined by Kaplan-Meier analyses and both univariate and multivariate Cox proportional hazards models. pKt/V measurements were available in 2434 (63%) of the 3841 individuals that began PD treatment in Australia and New Zealand during the study period. These patients were divided into 4 groups according to their baseline pKt/V values: <1.45 (n = 599), 1.45 - 1.69 (n = 550), 1.70 - 2.00 (n = 607), and >2.00 (n = 678). Compared with the reference group (pKt/V 1.70 - 2.00), patient mortality was significantly increased in individuals with pKt/V <1.45 [adjusted hazard ratio (HR) 1.87, 95% confidence interval (CI) 1.24 - 2.84; p = 0.003] and tended to be increased in those with pKt/V 1.45 - 1.69 (adjusted HR 1.46, 95% CI 0.96 - 2.21; p = 0.074). Importantly, higher pKt/V values (>2.00) also tended to be associated with higher mortality (adjusted HR 1.42, 95% CI 0.96 - 2.11; p = 0.079). The other independent predictors of death were lower residual renal function (RRF), older age, peripheral vascular disease, diabetes mellitus, late referral, higher peritoneal permeability, and untreated hypertension. No interaction was observed between pKt/V, RRF, and survival. Death-censored technique failure was demonstrated to be significantly worse in the pKt/V 1.45 - 1.69 group (adjusted HR 1.36, 95% CI 1.03 - 1.79; p = 0.028), older individuals, and individuals with Asian racial origin. Initial peritoneal Kt/V significantly and independently influences patient survival in Australian and New Zealand PD patients. Overall survival appears to be optimal in the pKt/V range 1.70 - 2.00, with poorer outcomes observed above and below these values. In particular, survival is significantly worse when the achieved pKt/V is <1.45. In addition, RRF is an important independent predictor of patient survival in the Australian and New Zealand incident PD patient populations. The results of this study should therefore draw attention to the possible danger of not delivering adequate PD dose to patients with considerable RRF.

Long term outcome of patients with autosomal dominant polycystic kidney diseases receiving peritoneal dialysis

There is a general perception that patients with polycystic kidney disease on peritoneal dialysis have poor long-term technique survival. In order to test this opinion, we performed a retrospective analysis comparing results of 56 consecutive patients with polycystic kidney disease to 56 non-diabetic patients with bilateral small kidneys. The patient groups were all initiated on peritoneal dialysis over a 12 year period and matched for age, gender and years of end stage renal failure. After a mean follow-up period of 37 months the two groups were statistically indistinguishable in terms of mortality, kidney transplantation-censored technique survival, median death-censored technique survival, the number of patients switched permanently to hemodialysis due to technique failure and the rate of peritonitis. On Cox regression (multivariate) analysis, only the baseline serum albumin level was a significant and independent risk factor of death-censored technique failure. Our study found no difference in long term outcome of peritoneal dialysis therapy in patients with polycystic kidney disease compared to a non-diabetic matched control group.

Automated and continuous ambulatory peritoneal dialysis have similar outcomes

We compared survival and death-censored technique survival in patients on automated peritoneal dialysis (automated dialysis) or on continuous ambulatory peritoneal dialysis. All 4128 patients from the Australia and New Zealand Dialysis and Transplant Registry who started peritoneal dialysis over a 5-year period through March 2004 were included. Times to death and death-censored technique failure were analyzed by Cox proportional hazards models while a conditional risk set model computed technique failure. Compared to patients treated entirely with continuous ambulatory peritoneal dialysis, automated peritoneal dialysis patients were more likely to be young, Caucasian, have marginally lower body mass index, and were less likely to have baseline cardiovascular disease or diabetes. Using univariate and multivariate analysis, our study showed there were no significant differences in patient survival and death-censored technique failure between the two types of peritoneal dialysis modalities.

High Peritoneal Permeability is Not Associated with Higher Mortality or Technique Failure in Patients on Automated Peritoneal Dialysis

Patients on continuous ambulatory peritoneal dialysis (CAPD) who have high small-molecule peritoneal transport have increased mortality. To investigate the impact of baseline peritoneal transport characteristics on patient and technique survival in incident peritoneal dialysis (PD) patients, most of whom are on automated PD (APD), with the use of icodextrin. Retrospective observational cohort study. A single PD unit. 193 new patients that began PD between January 2000 and September 2004, and had an initial peritoneal equilibration test within 6 months of commencement of PD. Patients were divided into low (L), low average (LA), high average (HA), and high (H) peritoneal transport groups. Death-censored technique failure and patient survival were examined. Of the 193 patients, 151 (78.1%) were on APD or on APD with icodextrin or on CAPD with icodextrin. At the end of 1, 3, and 5 years, patient survival was 91%, 82%, and 67% in LA group; 95%, 77%, and 69% in HA group; and 96%, 71%, and 71% in H group. Technique survival was 100%, 90%, and 77% in LA group; 96%, 84%, and 72% in HA group; and 92%, 87%, and 77% in H group. High peritoneal permeability did not predict worse patient survival or technique failure, while age, diabetes, a lower glomerular filtration rate, and high body mass index (> or =30 kg/m(2)) were independent predictors of death. This study suggests that higher peritoneal transport is not a significant independent risk factor for either mortality or death-censored technique failure. The favorable outcome for high transporters in this study may be due to improved management of volume status by the increased use of APD and the use of icodextrin-based dialysis fluid.

Meta-Analysis

Peritoneal membrane solute transport in peritoneal dialysis (PD) patients is assessed by the peritoneal equilibration test, which measures the ratio of creatinine in the dialysate to plasma after a standardized 4-h dwell (D/Pc). Patients then are classified as high, high-average, low-average, or low transporters on the basis of this result. A meta-analysis of observational studies was carried out to characterize the relationship between D/Pc and mortality and technique failure in patients who are on PD. Citations were identified in Medline by using a combination of Medical Subject Heading search terms and key words related to PD, peritoneal membrane permeability/transport, and mortality and technique failure. The table of contents of relevant journals and bibliographies of relevant citations were reviewed in duplicate. Twenty studies that met study criteria were identified. Nineteen studies were pooled to generate a summary mortality relative risk of 1.15 for every 0.1 increase in the D/Pc (95% confidence interval 1.07 to 1.23; P < 001). This result equated to an increased mortality risk of 21.9, 45.7, and 77.3% in low-average, high-average, and high transporters, respectively, as compared with patients with low transport status. Meta-regression analysis showed that the proportion of patients who were on continuous cycler PD within a study was inversely proportional to the mortality risk (P = 0.05). The pooled summary relative risk for death-censored technique failure was 1.18 (95% confidence interval 0.96 to 1.46; P = 0.12) for every 0.1 increase in the D/Pc. This meta-analysis demonstrates that a higher peritoneal membrane solute transport rate is associated with a higher mortality risk and a trend to higher technique failure.

Higher Peritoneal Transport Status Is Associated with Higher Mortality and Technique Failure in the Australian and New Zealand Peritoneal Dialysis Patient Populations

Although early studies observed that peritoneal membrane transport characteristics were determinants of morbidity and mortality in peritoneal dialysis (PD) patients, more recent investigations, such as the Ademex trial, have refuted these findings. The aim of this study was to determine whether baseline peritoneal transport status predicted subsequent survival in Australian and New Zealand PD patients. The study included all adult patients in Australia and New Zealand who commenced PD between April 1, 1999, and March 31, 2004, and had a peritoneal equilibration test (PET) performed within 6 mo of PD commencement. Times to death and death-censored technique failure were examined by Kaplan-Meier analyses and multivariate Cox proportional hazards models. PET measurements were available in 3702 (72%) of the 5170 individuals who began PD treatment in Australia or New Zealand during the study period. In these patients, high transporter status was found to be a significant, independent predictor of death-censored technique failure (adjusted hazard ratio [AHR] 1.23; 95% confidence interval [CI] 1.02 to 1.49; P = 0.03) and mortality (AHR 1.34; 95% CI 1.05 to 1.79, P = 0.02) compared with low-average transport status. High-average transport class was also associated with mortality (AHR 1.21; 95% CI 1.00 to 1.48; P = 0.047) but not death-censored technique failure (AHR 1.04; 95% CI 0.90 to 1.21) compared with low-average transport status. When transport status was alternatively analyzed as a continuous variable, dialysate:plasma creatinine ratio at 4 h was independently predictive of both death-censored technique failure (AHR 1.07; 95% CI 1.01 to 1.295; P = 0.031) and death (AHR 1.09; 95% CI 1.01 to 1.373; P = 0.036 per 0.1 change in dialysate:plasma creatinine). Peritoneal transport rate is a highly significant risk factor for both mortality and death-censored technique failure in the Australian and New Zealand incident PD patient populations.

Effect of previously failed kidney transplantation on peritoneal dialysis outcomes in the Australian and New Zealand patient populations

There is limited information about the outcomes of patients commencing peritoneal dialysis (PD) after failed kidney transplantation. The aim of the present study was to compare patient survival, death-censored technique survival and peritonitis-free survival between patients initiating PD after failed renal allografts and those after failed native kidneys. The study included all patients from the ANZDATA Registry who started PD between April 1, 1991 and March 31, 2004. Times to death, death-censored technique failure and first peritonitis episode were examined by multivariate Cox proportional hazards models. For all outcomes, conditional risk set models were utilized for the multiple failure data, and analyses were stratified by failure order. Standard errors were calculated by using robust variance estimation for the cluster-correlated data. In total, 13,947 episodes of PD were recorded in 23,579 person-years. Of these, 309 PD episodes were started after allograft failure. Compared with PD patients who had never undergone kidney transplantation, those with failed renal allografts were more likely to be younger, Caucasian, New Zealand residents and life-long non-smokers with lower body mass index (BMI), poorer initial renal function and a longer period from commencement of the first renal replacement therapy to PD. On multivariate analysis, PD patients with failed kidney transplants had comparable patient mortality [weighted hazards ratio (HR) 1.09, 95% confidence interval (CI) 0.81-1.45, P = 0.582], death-censored technique failure (adjusted HR 0.91, 95% CI 0.75-1.10, P = 0.315) and peritonitis-free survival (adjusted HR 0.92, 95% CI 0.72-1.16, P = 0.444) with those PD patients who had failed native kidneys. Similar findings were observed in a subset of patients (n = 5496) for whom peritoneal transport status was known and included in the models as a covariate. Patients commencing PD after renal allograft failure experienced outcomes comparable with those with failed native kidneys. PD appears to be a viable option for patients with failed kidney allografts.