Choice Of Dialysis Modality Research Articles

Choice of dialysis modality

Few medical decisions have as profound an impact on every aspect of a patient's life as the selection of dialysis modality by a patient with end-stage renal disease. It remains uncertain whether the outcome differences seen between hemodialysis and peritoneal dialysis patients, if any, in observational studies are attributable to the dialysis modality. Such studies, thus, are insufficient to deny patients a choice in selecting their dialysis modality.

Nephrology literature watch

Nephrology literature watch

Growing a peritoneal dialysis program: A single‐center experience

Growing a peritoneal dialysis program: A single‐center experience

The effect of bundling on peritoneal dialysis: Challenges and opportunities to improve outcomes and change the “default”

The effect of bundling on peritoneal dialysis: Challenges and opportunities to improve outcomes and change the “default”

Nephrology Literature Watch

Nephrology Literature Watch

The D&T Report

The D&T Report

Effects of comorbid and demographic factors on dialysis modality choice and related patient survival in Europe

The mean age of patients starting dialysis increased over the years, as has the proportion of patients with diabetes mellitus, ischaemic heart disease, peripheral vascular disease (PVD), cerebrovascular disease (CD) and malignancy. We assessed dialysis modality choice within subgroups of patients with these comorbidities and in different age categories and subsequently evaluated the association between modality choice and patient survival in these subgroups. Seven European renal registries participating in the ERA-EDTA Registry provided data from 15,828 incident peritoneal dialysis (PD) and haemodialysis (HD) patients (1998-2006) with available comorbidity data. The likelihood to receive PD rather than HD was assessed with logistic regression and 3-year survival on PD versus HD was evaluated using Cox regression. Besides large international variations in the likelihood to receive PD, we found that elderly patients and patients with PVD, CD, malignancy and multiple comorbidities were significantly less likely to receive PD than HD. Overall patients starting on PD had survival benefits [adjusted hazard ratio (HR(adj)) 0.82 (0.75-0.90)], especially patients without comorbidity [HR(adj) 0.65 (0.53-0.80)] or those with malignancy [HR(adj) 0.73 (0.56-0.94)]. In males, survival benefits of PD were independent of diabetic status. Conversely, diabetic females tended to have increased mortality risk on PD [HR(adj) 1.16 (0.93-1.44)], especially if they were >70 years [HR(adj) 1.55 (1.15-2.08)]. In general, modality choice was consistent with expected survival. However, elderly patients, non-diabetic patients and those with malignancy were less likely to receive PD, even though they had decreased mortality risk on PD. Also, although a survival benefit of PD was found for male patients without comorbidity, HD was just as likely to be the chosen dialysis modality as was PD for these patients.

Timing of dialysis initiation and choice of dialysis modality

Few, if any, doubt that renal transplantation should be the first choice of renal replacement therapy whenever this option is possible. But, at which level of remaining kidney function should patients start on dialysis and which dialysis modality should be used? Several studies published in 2010 addressed these questions and will influence dialysis initiation strategies worldwide for years to come.

Can quality of life be improved for the increasing numbers of older patients with end-stage kidney disease?

Quality of life is particularly important for older patients with end-stage kidney disease, particularly when likely survival is short because of the burden of comorbidities. The features of old age and frailty make it difficult to cope with both hemodialysis and peritoneal dialysis. Evidence exists that quality of life is better on peritoneal dialysis compared with hemodialysis, yet the majority of older patients are placed on hemodialysis. Older patients should therefore receive appropriate education to enable choice of the appropriate dialysis modality for their lifestyle. The development of assisted peritoneal dialysis will enable those who cannot perform their own dialysis to have their treatment at home. Delaying dialysis to a time when it is actually needed and discussing the option of conservative care will also improve the quality of the end-of-life phase for patients with multiple comorbidities and with a poor overall prognosis.

Choice of Dialysis Modality in the United States

Choice of Dialysis Modality in the United States

Acute Kidney Injury After Liver, Heart, and Lung Transplants: Dialysis Modality, Predictors of Renal Function Recovery, and Impact on Survival

Recipients of nonrenal organ transplants including the liver, heart, and lung are at risk for developing acute kidney injury (AKI) and chronic kidney disease (CKD). Underlying hepatic or cardiopulmonary failure, prolonged intraoperative hemodynamic instability, and the use of calcineurin inhibitors and nephrotoxic medications have all been suggested to be contributory. The incidence of perioperative AKI has been reported to occur in 17% to 95% in liver transplant recipients, 5% to 30% in heart transplant recipients, and 5% to 60% in recipients of lung transplants. Among those who develop AKI, renal replacement therapy is required in 5% to 35%, 5% to 15%, and 8% to 10% in liver, heart, and lung transplant recipients, respectively. The current article presents an overview of the literature on the choice of dialysis modality and its associated advantages and disadvantages in the management of AKI after liver, heart, and lung transplants. Predictive factors for renal function recovery and the impact of AKI and CKD on survival will also be discussed.

The Economics of Home Dialysis: Acting for the Individual While Planning Responsibly for the Population

Traditional medical education paradigms tend not to focus on health economics and economic evaluation. This has led to a culture in which bedside clinicians simply allocate health care resources made available to them, with often minimal input as to what these resources are at the population or health care system level. Life sustaining chronic dialysis therapies for end-stage renal disease are heterogeneous in terms of health care costs and the quality of life provided to patients receiving them. From the traditional clinician's perspective, they may be considered equivalent because there are no well-designed randomized control trials establishing the superiority of one particular dialysis modality in terms of all-cause mortality or cardiovascular events. The intent of this review is to provide clinicians practicing in the area of chronic kidney disease some insights into the concepts of economic evaluation and how it may be integrated into clinical decision making at a programmatic level while not compromising individual patient care at the bedside. An epidemiologic perspective will be used to help frame how the implementation of home dialysis modalities vary depending on local health policies in place. Lessons learned by regional nephrology care systems may be readily transferable to other jurisdictions in augmenting the uptake of home dialysis modalities where they are dwindling or struggling to grow. A high-level understanding of economic data in this area may help influence health policy in the direction of the most efficient provision of dialysis to patients while not adversely affecting their quality of life or health outcomes.

Sustained low-efficiency dialysis versus continuous veno-venous hemofiltration for postsurgical acute renal failure

Background In postsurgical acute renal failure patients with moderate unstable hemodynamics or fluid overload, the choice of dialysis modality is difficult. This study was performed to compare the outcomes between the sustained low-efficiency dialysis (SLED) and continuous veno-venous hemofiltration (CVVH) in these patients. Methods Sequential postsurgical acute renal failure patients undergoing acute dialysis with CVVH (2002–2003), or SLED (2004–2005) as a result of severe fluid overload or moderately unstable hemodynamics were analyzed. Multivariate analyses of comorbidity, disease severity before initiating dialysis, biochemical measurements, and hemodynamic parameters for 3 days after the first dialysis session were performed by fitting multiple logistic regression models to predict patient's 30-day after hospital discharge (AHD) mortality. Results Among the 101 recruited patients, 38 received SLED and the rest received CVVH. The 30-day AHD mortality was 62.4%. The independent risk factors of 30-day AHD mortality included older age ( P = .008), lower first postdialysis mean arterial pressure (MAP) ( P = .021), higher first postdialysis blood urea nitrogen level ( P = .009), and absence of a history of hypertension ( P = .002). A further linear regression analysis found that dialysis using SLED was associated with higher first postdialysis MAP ( P = .003). Conclusions Among the postsurgical patients requiring acute dialysis with severe fluid overload or moderately unstable hemodynamics, the patients treated with SLED had a higher first postdialysis MAP than those treated with CVVH, which led to lower mortality. Further multicenter randomized clinical trials of larger sample size are needed to compare the effects of SLED and CVVH on the outcomes of postsurgical acute dialysis patients.

Comparison of markers of oxidative stress, inflammation and arterial stiffness between incident hemodialysis and peritoneal dialysis patients – an observational study

BackgroundPatients on peritoneal and hemodialysis have accelerated atherosclerosis associated with an increase in cardiovascular morbidity and mortality. The atherosclerosis is associated with increased arterial stiffness, endothelial dysfunction and elevated oxidative stress and inflammation. The aims of this study are to investigate the effects of peritoneal and hemodialysis on arterial stiffness, vascular function, myocardial structure and function, oxidative stress and inflammation in incident patients with end stage kidney disease.MethodsThis is an observational study. Eighty stage five CKD patients will be enrolled and followed for one-year. Primary outcome measures will be changes in 1) arterial stiffness measured by aortic pulse wave velocity, 2) oxidative stress assessed by plasma F2 isoprostanes and 3) inflammation measured by plasma pentraxin-3. Secondary outcomes will include additional measures of oxidative stress and inflammation, changes in vascular function assessed using the brachial artery reactivity technique, carotid artery intimal medial thickness, augmentation index and trans thoracic echocardiography to assess left ventricular geometry, and systolic and diastolic function. Patients will undergo these measures at baseline (6–8 weeks prior to starting dialysis therapy), then at six and 12 months after starting dialysis.DiscussionThe results of this study may guide the choice of dialysis modality in the first year of treatment. It may also lead to a larger study prospectively assessing the effect of dialysis modality on cardiovascular morbidity and mortality.Trial RegistrationACTRN12609000049279

Peritoneal Dialysis in the Pediatric Intensive Care Unit Setting

Acute kidney injury (AKI) is a common complication in pediatric and neonatal intensive care units (ICUs). Renal replacement therapy (RRT) is frequently needed in children in whom supportive therapy is not enough to satisfy metabolic demands or to provide adequate nutrition in cases of oliguric kidney failure. The decision to begin dialysis should not be delayed, because experience in infants shows that the shorter the time from the ischemic insult to the beginning of dialysis, the higher the survival rate. The use of continuous RRT (CRRT) in pediatric patients in the ICU has almost tripled; at the same time, the use of peritoneal dialysis (PD) and intermittent hemodialysis has markedly declined. Patient age seems to be the most important factor influencing the decision on the choice of dialysis modality. Although CRRT is reported as the preferred dialysis modality for acutely ill children, PD is still the most common modality used in patients under 6 years of age. Among the several advantages that PD offers, relatively low cost is probably the most significant. Other advantages include technical simplicity, lack of a need for anticoagulation or placement of a central venous catheter, and excellent tolerance in hemodynamically unstable patients. Much controversy exists regarding the adequacy of PD in hypercatabolic patients in the ICU. Nonetheless, when Kt/V has been applied to acutely ill children, it has been shown that PD can provide adequate clearances for most infants. No prospective studies have evaluated the effect of dialysis modality on the outcomes of children with AKI in the ICU setting. The decision about dialysis modality should therefore be based on local expertise, resources available, and the patient's clinical status.

Choosing the dialysis method for kidney transplant patients with advanced kidney disease

The choice of the most of dialysis modality after renal graft loss is an unanswered question. Most patients start hemodialysis (HD) in this situation, because of several reasons: 1. In most dialysis programs HD predominates clearly over Peritoneal Dialysis (PD). 2. The star of dialysis in emergency situations makes the physician use HD 3. The fear of infections in case of maintenance of immunosupression to avoid immune response and to keep residual renal function in case of PD. A lot of patients could undergo PD in order to maintain the previous style of life, as an alternative in case of absence of vascular access and to avoid vascular accesses in children. Mortality seems to be greater in patients with graft loss than in those who start dialysis for the first time, although the comparison between both groups is methodologically difficult. However, there is no difference in mortality between patients who start HD and those who start PD. Studies comparing the rate of peritonitis in PD patients in both groups find controversial results. The analysis of the few, retrospective and biased studies which look for differences in patient survival in HD and DP suggests that prognosis of both groups is similar. The choice of dialysis modality must be similar to those patients which begin dialysis for the first time.

PREVALENCE OF COGNITIVE IMPAIRMENT IN PATIENTS ATTENDING PRE‐DIALYSIS CLINIC

Approximately 20-30% of patients on renal replacement therapy (RRT) have cognitive impairment. Less is known about the prevalence of cognitive impairment in patients with advanced kidney disease awaiting the initiation of dialysis. Routine cognitive assessment was implemented in the pre-dialysis clinic, which enabled the Nephrologist and Pre-dialysis Nurse to identify those patients with impaired cognitive function and utilise this information to assess the suitability for self-care treatments, such as peritoneal dialysis, as well as to adapt information to meet their needs. Subsequently, a cross-sectional single-centre audit was undertaken to identify the prevalence of cognitive impairment in 132 consecutive new referrals to the pre-dialysis clinic using the Mini-mental State Examination (MMSE). Twenty percent (95% CI = 0.13, 0.27) were classified as cognitively impaired. Those with cognitive impairment were significantly older, and had lower eGFR and higher serum creatinine. It can be concluded that approximately 1 in 5 patients attending the pre-dialysis clinic has cognitive impairment, which may not be apparent on a routine clinical history. Cognitive function assessment is recommended for all, but particularly to the older patient, before advising on choice of dialysis modality or opting for conservative treatment.

Patients' views regarding choice of dialysis modality

Increasing patient numbers have resulted in pressure on dialysis centres and a need to reorganize dialysis treatment. This study explored patients' experiences with different dialysis modalities and investigated issues related to the patient's choice of modality, especially 'out-of-centre' dialysis (i.e. modalities other than CHD). Six focus group interviews were conducted with 24 dialysis patients, 3 pre-dialysis patients and 18 relatives. Each focus group comprised patients on one type of dialysis, i.e. CHD, self-care CHD, HHD, CAPD/APD, aAPD or pre-dialysis patients. Based on a semi-structured interview guide, the group discussions centred on advantages and disadvantages of dialysis modalities, problems experienced and their (possible) solutions and patient involvement in choice of modality. The focus groups participants considered that each dialysis modality has its advantages and disadvantages. Flexibility, independence and feelings of security were key factors in determining choice of modality, with maintenance of a normal life being a major goal. Patients and their relatives want to participate in choice of modality, but a genuine offer of out-of-centre dialysis including professional support and appropriate and timely education is needed to encourage a greater use of modalities other than CHD. No single dialysis modality emerged as offering the best solution for patients with end-stage renal disease. In the absence of absolute clinical contraindications, the treatment of choice should be the modality that best accommodates the patients' preferences for their daily activities and lifestyle. A move towards more patients on out-of-centre dialysis requires a greater focus on pre-dialysis patients and closer consideration of patients' preferences and current lifestyle.

Preparing Patients for Peritoneal Dialysis

When told of their need for dialysis, patients often cannot accept it and are fearful toward dialysis. Pre-dialysis counseling programs help patients to face dialysis, to make the right choice of dialysis modality, and to prepare themselves for life on dialysis. Clear explanations of peritoneal dialysis (PD) help patients choosing PD. Patients should be referred to pre-dialysis programs at least 4 - 6 months before commencement of dialysis or when their glomerular filtration rate is around 15 mL/min/1.73 m(2). The pre-dialysis program is best conducted by experienced staff such as renal nurses and multidisciplinary staff including nephrologists, dietitians, physiotherapists, psychologists, social workers, or even dialysis patient representatives depending on availability. The program should be designed according to the culture, settings, staff availability, and patient load in individual hospitals. Pre-dialysis home visits may be needed in some cases to assess suitability and prepare the home for PD.

Reimbursement and economic factors influencing dialysis modality choice around the world

The worldwide incidence of kidney failure is on the rise and treatment is costly; thus, the global burden of illness is growing. Kidney failure patients require either a kidney transplant or dialysis to maintain life. This review focuses on the economics of dialysis. Alternative dialysis modalities are haemodialysis (HD) and peritoneal dialysis (PD). Important economic factors influencing dialysis modality selection include financing, reimbursement and resource availability. In general, where there is little or no facility or physician reimbursement or payment for PD, the share of PD is very low. Regarding resource availability, when centre HD capacity is high, there is an incentive to use that capacity rather than place patients on home dialysis. In certain countries, there is interest in revising the reimbursement structure to favour home-based therapies, including PD and home HD. Modality selection is influenced by employment status, with an association between being employed and PD as the modality choice. Cost drivers differ for PD and HD. PD is driven mainly by variable costs such as solutions and tubing, while HD is driven mainly by fixed costs of facility space and staff. Many cost comparisons of dialysis modalities have been conducted. A key factor to consider in reviewing cost comparisons is the perspective of the analysis because different costs are relevant for different perspectives. In developed countries, HD is generally more expensive than PD to the payer. Additional research is needed in the developing world before conclusive statements may be made regarding the relative costs of HD and PD.