Initial Dialysis Modality Research Articles

Association between initial and pretransplant dialysis modality and graft and patient outcomes in live- and deceased-donor renal transplant recipients

The association between pretransplant dialysis modality and transplant outcomes remains inconsistent. The aim of this study is to address the association between alteration in dialysis modality and post-transplant outcomes. Using Australia and New Zealand Dialysis and Transplant Registry, primary live- and deceased-donor renal transplant recipients (RTR) between 1997 and 2009 were examined. Pre-emptive and multiple-organ transplants were excluded. The association between initial and pretransplant dialysis modality and transplant outcomes were examined. Of the 6701 RTR, 18.6% were initiated-maintained on peritoneal dialysis pretransplant (PD-PD), 9.2% were initiated on PD, but maintained on haemodialysis (HD) pretransplant (PD-HD), 63.3% were HD-HD and 8.9% were HD-PD. PD-HD [odds ratio(OR)1.44, 95% CI 1.21,1.72] and HD-HD (OR1.25, 95% CI 1.12,1.41) were associated with a significantly greater risk of slow graft function compared with the overall mean of the groups, whereas a change in initial dialysis modality from HD to pretransplant PD was associated with higher risk of overall graft failure [hazard ratio(HR)1.19, 95% CI 1.04,1.36) and recipient death (HR1.34, 95% CI 1.13,1.59). Our registry analysis suggest that dialysis modality pretransplant may affect transplant outcomes and future studies evaluating patient selection, choice of modality and/or potential interventions in the pre and post-transplant period may have a beneficial effect on post-transplant outcomes.

Relationship of body size and initial dialysis modality on subsequent transplantation, mortality and weight gain of ESRD patients

Whether peritoneal dialysis (PD) treatment leads to greater weight gain than with hemodialysis (HD) and if this limits access of obese end-stage renal disease patients to renal transplantation has not been examined. We undertook this study to determine the interrelationship between body size and initial dialysis modality on transplantation, mortality and weight gain. Time to transplantation, time to death and weight gain were estimated in a 1:1 propensity score-matched cohort of incident HD and PD patients treated in facilities owned by DaVita Inc. between 1 July 2001 through 30 June 2006 followed through 30 June 2007 (4008 pairs) in four strata of body mass index (BMI) (<18.5, 18.5-24.99, 25.00-29.99 and ≥ 30 kg/m(2)). Transplantation was significantly more likely in PD patients [adjusted hazards ratio (aHR) 1.48, 95% confidence interval (95% CI) 1.29-1.70]; the probability of receiving a kidney transplant was significantly higher in each strata of BMI >18.5 kg/m(2), including with BMI ≥ 30 kg/m(2) (aHR 1.45, 95% CI 1.11-1.89). PD patients had significantly lower all-cause mortality for patients with BMI 18.50-29.99 kg/m(2). Both these findings were confirmed on analyses of the entire unmatched incident cohort (PD 4008; HD 58 471). The effect of dialysis modality on weight gain was tested in 687 propensity score-matched pairs; the odds of >2, >5 or >10% weight gain were significantly lower in PD patients. Treatment with PD is less likely to be associated with a significant weight gain and does not limit the access of obese patients to renal transplantation.

Impact of Dialysis Modality on Survival after Kidney Transplant Failure

An increasing number of patients are returning to dialysis after allograft loss (DAGL). These patients are at a higher mortality risk compared with incident ESRD patients. Among transplant-naïve patients, those treated with peritoneal dialysis (PD) enjoy an early survival advantage compared with those treated with hemodialysis (HD), but this advantage is not sustained over time. Whether a similar time-dependent survival advantage exists for PD-treated patients after allograft loss is unclear and may impact dialysis modality selection in these patients. We identified 2110 adult patients who initiated dialysis after renal transplant failure between January 1991 and December 2005 from The Canadian Organ Replacement Register. Multivariable regression analysis was used to evaluate the impact of initial dialysis modality on early (2 years), late (after 2 years), and overall mortality using an intention-to-treat approach. After adjustment, there was no difference in overall survival between HD- and PD-treated patients (hazard ratio((HD:PD)), 1.05; 95% confidence interval, 0.85 to 1.31), with similar results seen for both early and late survival. Superior survival was seen in more contemporary cohorts of patients returning to DAGL. The use of PD compared with HD is associated with similar early and overall survival among patients initiating DAGL. Differences in both patient characteristics and predialysis management between patients returning to DAGL and transplant-naive incident dialysis patients may be responsible for the absence of an early survival advantage with the use of PD in DAGL patients.

Renal Function Recovery in Chronic Dialysis Patients

Renal function recovery (RFR) from acute kidney injury requiring dialysis occurs at a high frequency. RFR from chronic dialysis, on the other hand, is an uncommon but well-recognized phenomenon, occurring at a rate of 1.0-2.4% according to data from large observational studies. The underlying etiology of renal failure is the single most important predicting factor of RFR in chronic dialysis patients. The disease types with the highest RFR rates are atheroembolic renal disease, systemic autoimmune disease, renovascular diseases, and scleroderma. The disease types with the lowest RFR rates are diabetic nephropathy and cystic kidney disease. Initial dialysis modality does not appear to influence RFR. Careful observation and history taking are needed to recognize the often nonspecific clinical and laboratory signs of RFR. When RFR is suspected in a chronic dialysis patient, a 24-hour urine urea and creatinine clearance should be measured. Based on the renal clearance, along with other clinical factors, the dialysis prescription may be gradually reduced until a complete discontinuation of dialysis. After RFR from maintenance dialysis, patients require close follow-up in an office setting for chronic kidney disease management.

Patient Awareness and Initiation of Peritoneal Dialysis

Few US patients with kidney failure start treatment on peritoneal dialysis (PD) despite its potential survival, quality of life, and cost-saving benefits. We investigated patient awareness of PD and variables associated with PD selection, including dialysis unit ownership and geographic area. In a cohort study, incident dialysis patients identified by the Centers for Medicare and Medicaid Services (CMS) and included in the United States Renal Data System (USRDS) were surveyed from 2005 to 2007 for the USRDS Comprehensive Dialysis Study. Participants reported whether PD had been discussed with them before they started regular treatment for kidney failure, and initial dialysis modality was verified in the USRDS patient registry. The proportion of patients in our study cohort who reported that PD had been discussed with them (61%) was higher than in previous surveys, but only 10.9% of informed patients initiated PD. With patient demographic and clinical characteristics controlled for, the proportion of informed patients who started PD differed substantially across large dialysis organizations. Substantial variation in selection of PD was also evident among patients starting dialysis in the 18 end-stage renal disease Network areas. Despite patients' early awareness of PD as a treatment option, PD selection was low in this national cohort. Factors associated with PD selection merit continued study as CMS seeks to improve quality and cost-effectiveness of kidney patient care.

The Sudan Peritoneal Dialysis Program: Three Years of Momentum

Introduction: End stage renal disease (ESRD) is a significant social and economic burden on Africa. Continuous ambulatory peritoneal dialysis (CAPD) was introduced as a national service in the Sudan three years ago. An overview of the Sudan Peritoneal Dialysis Program is presented. Review: As a national scheme, the Sudan PD program was sequentially launched in seven centers in Sudan. CAPD was the modality exclusively utilized. The total number of patients enrolled by July 2008 was 232. Patients' mean age was 43 years, 23.5% were children, 63% were males, and 19% were diabetic. PD was the initial dialysis modality for 54.7% of patients, 43.5% were referred from HD, and 1.9% had a failed kidney transplant. The majority of patients (62.3%) chose PD as the preferred dialysis modality, while the remainder were referred from HD to PD because of vascular access problems or hemodynamic instability. One third of patients required assisted PD, and 17% needed urgent initiation of dialysis. The cumulative peritonitis rate was one episode per 10.8 patient months. Touch contamination, urgent initiation of dialysis and execution of dialysis by family members other than trained helpers were among the identified predisposing factors. Conclusion: The establishment and operation of the Sudan PD program over the past three years have indicated that it is a promising project with multifaceted success. There is, however, an ongoing need for retraining of patients and staff. Early selection and careful preparation for potential PD candidates is also of vital importance to reduce the need for urgent dialysis initiation. Key words: peritoneal dialysis, CAPD, renal replacement therapy, Sudan, Africa

Comparison of patient survival in non-diabetic transplant-listed patients initially treated with haemodialysis or peritoneal dialysis

It is still not known whether patients survive longer on one modality of dialysis compared to the other. We have tried to answer this question using data from the Scottish Renal Registry. To avoid the confounding effects of co-morbidity, we limited our survival analysis to those patients listed for a renal transplant and excluded patients with a primary renal diagnosis (PRD) of diabetic nephropathy. We studied patients starting dialysis between 01 January 1982 and 31 December 2006. Three thousand one hundred and ninety-seven patients fulfilled our criteria. A Kaplan-Meier plot showed no difference in survival between initial dialysis modality (log-rank P = 0.996). In the Cox regression model, initial dialysis modality was not a significant predictor of survival; hazard ratio = 0.97 (95% CI 0.80 to 1.18) after adjusting for age, sex and PRD. Age at the start of dialysis, hazard ratio = 1.05 (95% CI 1.04 to 1.06) and a PRD group of 'multi-system disease' or 'unknown' were found to significantly influence survival. When survival was also censored for change in modality, there was no difference in survival over the whole study period with the hazard of death for patients on haemodialysis compared to those on peritoneal dialysis being 1.04 (95% CI 0.78 to 1.38; P = 0.803). Age at the start of dialysis remained a significant predictor of death. This study shows that there was no survival advantage between initial dialysis modalities in non-diabetic patients who are deemed healthy enough for listing for a renal transplant.

Recovery of renal function in end-stage renal failure--comparison between peritoneal dialysis and haemodialysis

Recovery of dialysis-independent renal function in long-term dialysis patients has not been studied extensively. The aim of this study was to investigate the effect of dialysis modality on the likelihood, timing and durability of recovery of dialysis-independent renal function. The study reviewed all patients in Australia and New Zealand who commenced dialysis for treatment of end-stage renal disease (ESRD) between 1963 and 2006. Dialysis modality was assigned at 90 days. A supplementary analysis was also conducted using a contemporary cohort that included data on comorbidities, smoking and eGFR at dialysis onset. During the study period, 15 912 individuals received peritoneal dialysis (PD) and 23 658 received haemodialysis (HD). Renal recovery occurred in 176 (1.1%) PD and 244 (1.0%) HD patients. Using multivariate Cox proportional hazards regression analyses, dialysis modality was not independently predictive of time to renal recovery (HR 0.92, 95% CI 0.76-1.13, P = 0.4). Recovery was significantly more likely in patients with higher baseline eGFR, with no hypertension or peripheral vascular disease, and with certain causes of kidney failure (autoimmune renal disease, haemolytic uraemic syndrome, interstitial nephritis, obstructive uropathy, paraproteinaemia and renovascular nephrosclerosis). Recovery was less likely in Maori/Pacific Islanders and polycystic kidney disease. Among patients who recovered, 328 (78%) subsequently experienced renal death, mostly within the first year. The duration of renal recovery was not associated with initial dialysis modality (OR 0.82, 95% CI 0.50- 1.32). Dialysis modality is not associated with the likelihood, timing or durability of spontaneous recovery of dialysis-independent renal function in patients thought to have ESRD.

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.

Associations of Dialysis Modality and Infectious Mortality in Incident Dialysis Patients in Australia and New Zealand

The aim of the present investigation is to compare rates, types, causes, and timing of infectious death in incident peritoneal dialysis (PD) and hemodialysis (HD) patients in Australia and New Zealand. Observational cohort study using the Australian and New Zealand Dialysis and Transplant Registry data. The study included all patients starting dialysis therapy between April 1, 1995, and December 31, 2005. Dialysis modality. Rates of and time to infectious death were compared by using Poisson regression, Kaplan-Meier, and competing risks multivariate Cox proportional hazards model analyses. 21,935 patients started dialysis therapy (first treatment PD, n = 6,020; HD, n = 15,915) during the study period, and 1,163 patients (5.1%) died of infectious causes (PD, 529 patients; 7.6% versus HD, 634 patients; 4.2%). Incidence rates of infectious mortality in PD and HD patients were 2.8 and 1.7/100 patient-years, respectively (incidence rate ratio PD versus HD, 1.66; 95% confidence interval [CI], 1.47 to 1.86). After performing competing risks multivariate Cox analyses allowing for an interaction between time on study and modality because of identified nonproportionality of hazards, PD consistently was associated with increased hazard of death from infection compared with HD after 6 months of treatment (<6 months hazard ratio [HR], 1.08; 95% CI, 0.76 to 1.54; 6 months to 2 years HR, 1.31; 95% CI, 1.09 to 1.59; 2 to 6 years HR, 1.51; 95% CI, 1.26 to 1.80; >6 years HR, 2.76; 95% CI, 1.76 to 4.33). This increased risk of infectious death in PD patients was largely accounted for by an increased risk of death caused by bacterial or fungal peritonitis. Patients were not randomly assigned to their initial dialysis modality. Residual confounding and coding bias could not be excluded. Dialysis modality selection significantly influences risks, types, causes, and timing of fatal infections experienced by patients with end-stage kidney disease in Australia and New Zealand.

Associations between comorbidities, treatment choice and outcome in the elderly with end-stage renal disease

New patients treated for end-stage renal disease are increasingly elderly: in France, 38% are 75 years or older. The best treatment choices for the elderly are still debated. We studied case-mix factors associated with choice of initial dialysis modality and 2-year survival in the 3512 patients aged 75 years or older who started dialysis between 2002 and 2005 and were included in the French REIN registry. Overall, 18% began with peritoneal dialysis (PD), 50% with planned haemodialysis (planned HD) and 32% with unplanned HD, that is, HD that started on an emergency basis. At least one comorbid condition was reported for 85%, and three or more for 36%, but case-mix varied with age. PD was chosen significantly more often than planned HD for the oldest (> or =85) compared with the youngest (75-79) patients: odds ratio 2.1 (95% confidence interval, 1.5-2.8), in those with congestive heart failure: 1.8 (1.5-2.3) and severe behavioural disorder: 2.2 (1.3-3.5), but less often for obese patients: 0.5 (0.3-0.8) and smokers: 0.4 (0.2-0.9). Two-year survival rates were 58, 52 and 39% in patients aged 75-79, 80-84 and > or =85, respectively. Compared with planned HD, unplanned HD was associated with a risk of mortality 50% higher, and PD with a risk 30% higher, independent of patient case-mix. PD is a common treatment option in French elderly patients, but our study suggests the need for caution in the long-term use. The high frequency of unplanned HD would require further attention.

Cardiovascular disease in haemodialysis and peritoneal dialysis: arguments pro haemodialysis

In end-stage renal disease (ESRD) patients, congestive heart failure (CHF) is a dreadful complication. Its pathogenesis is multifactorial. Chronic arterial hypertension, uraemic cardiomyopathy, coronary artery disease (CAD) and valvular disease all lead to myocardial damage that may eventually result in CHF. Other more or less well-proven contributory factors are chronic volume overload, anaemia, metabolic acidosis, secondary hyperparathyroidism, the malnutrition-inflammation complex syndrome and the haemodialysis (HD) arterio-venous fistula (AVF). In the Dialysis Outcomes and Practice Patterns Study (DOPPS), the prevalence of CHF in the HD population was reported to be 46% in the US, but only 25% in Europe and as little as 6% in Japan [1]. Such substantial geographical differences may be explained in part by the fact that the US patients were older and had more diabetes, CAD and other vascular diseases than the European and Japanese patients, but they may also derive from different criteria for defining CHF. As a matter of fact, there is a risk of overdiagnosing CHF in ESRD patients who present with oedema, dyspnoea and enlarged heart, due to extracellular volume expansion. Therefore, a wide consensus on the definition of CHF in this setting is mandatory for a more accurate estimation of the magnitude of this phenomenon. Preventing and treating CHF is a critical task, since nowadays, over 80% of ESRD patients, recently diagnosed with CHF will die within just three years [2]. The topic we wish to debate here is the influence of the initial dialysis modality upon the outcome of patients with ESRD and CHF. In other words, what should we choose for such patients: HD or peritoneal dialysis (PD)? Unfortunately, to answer this dilemma, there is very little evidence to count on. Randomized survival studies are lacking, and for ethical reasons, such studies will probably never be conducted. A single comparative (but still non-randomized) HD vs PD study has been done so far, that specifically addressed the survival of ESRD patients with CHF, namely the one published by Stack et al., in 2003 [3]. Therefore, our discussion also needed to include other studies, comparing the influence of HD and PD upon ‘surrogate’ end points, like CHF risk factors, heart structure and function and risk of developing de novo CHF.

Survival by Dialysis Modality in Critically Ill Patients with Acute Kidney Injury

Among critically ill patients, acute kidney injury (AKI) requiring dialysis is associated with mortality rates generally in excess of 50%. Continuous renal replacement therapies (CRRT) often are recommended and widely used, although data to support its superiority over intermittent hemodialysis (IHD) are lacking. Data from the Program to Improve Care in Acute Renal Disease (PICARD), a multicenter observational study of AKI, were analyzed. Among 398 patients who required dialysis, the risk for death within 60 d was examined by assigned initial dialysis modality (CRRT [n = 206] versus IHD [n = 192]) using standard Kaplan-Meier product limit estimates, proportional hazards ("Cox") regression methods, and a propensity score approach to account for selection effects. Crude survival rates were lower for patients who were treated with CRRT than IHD (survival at 30 d 45 versus 58%; P = 0.006). Adjusted for age, hepatic failure, sepsis, thrombocytopenia, blood urea nitrogen, and serum creatinine and stratified by site, the relative risk for death associated with CRRT was 1.82 (95% confidence interval 1.26 to 2.62). Further adjustment for the propensity score did not materially alter the association (relative risk 1.92; 95% confidence interval 1.28 to 2.89). Among critically ill patients with AKI, CRRT was associated with increased mortality. Although the results could reflect residual confounding by severity of illness, these data provide no evidence for a survival benefit afforded by CRRT. Larger, prospective, randomized clinical trials to compare CRRT and IHD in severe AKI are needed.

Timing of Initiation of Dialysis in Critically Ill Patients with Acute Kidney Injury

Among critically ill patients, acute kidney injury (AKI) is a relatively common complication that is associated with an increased risk for death and other complications. To date, no treatment has been developed to prevent or attenuate established AKI. Dialysis often is required, but the optimal timing of initiation of dialysis is unknown. Data from the Program to Improve Care in Acute Renal Disease (PICARD), a multicenter observational study of AKI, were analyzed. Among 243 patients who did not have chronic kidney disease and who required dialysis for severe AKI, we examined the risk for death within 60 d from the diagnosis of AKI by the blood urea nitrogen (BUN) concentration at the start of dialysis (BUN < or = 76 mg/dl in the low degree of azotemia group [n = 122] versus BUN > 76 mg/dl in the high degree of azotemia group [n = 121]). Standard Kaplan-Meier product limit estimates, proportional hazards (Cox) regression methods, and a propensity score approach were used to account for selection effects. Crude survival rates were slightly lower for patients who started dialysis at higher BUN concentrations, despite a lesser burden of organ system failure. Adjusted for age, hepatic failure, sepsis, thrombocytopenia, and serum creatinine and stratified by site and initial dialysis modality, the relative risk for death that was associated with initiation of dialysis at a higher BUN was 1.85 (95% confidence interval 1.16 to 2.96). Further adjustment for the propensity score did not materially alter the association (relative risk 1.97; 95% confidence interval 1.21 to 3.20). Among critically ill patients with AKI, initiation of dialysis at higher BUN concentrations was associated with an increased risk for death. Although the results could reflect residual confounding by severity of illness, they provide a rationale for prospective testing of alternative dialysis initiation strategies in critically ill patients with severe AKI.

Mortality by Dialysis Modality among Patients Who Have End-Stage Renal Disease and Are Awaiting Renal Transplantation

Comparing outcomes related to dialysis modality is complicated by selection bias introduced by patients and physicians. To address the impact of selection bias, this study compared mortality by initial dialysis modality among patients who had ESRD and were placed on the transplant waiting list. This study was a historical prospective cohort of 12,568 patients in the United States who initiated dialysis between May 1, 1995, and October 31, 1998, and were placed on the transplant waiting list before dialysis initiation. Two-year mortality was compared using Kaplan-Meier curves and Cox proportional hazards models that analyzed patients primarily using an intention-to-treat approach and separately censored patients on a modality switch. At 2 yr, the unadjusted mortality rate was 6.6% among peritoneal dialysis (PD) patients compared with 6.9% among hemodialysis (HD) patients (hazard ratio [HR] 1.01; 95% confidence interval [CI] 0.82 to 1.23). After controlling for differences in baseline characteristics, comorbidities, and laboratory variables, the selection of PD versus HD remained associated with a similar 2-yr mortality risk (HR 1.03; 95% CI 0.83 to 1.28). In separate models, 2-yr mortality associated with PD versus HD was significant among patients with body mass index (BMI) > or = 26 kg/m2 (HR 1.37; 95% CI 1.01 to 1.83) but not among patients with BMI < 26 kg/m2 (HR 0.81; 95% CI 0.61 to 1.07). Results were similar after censoring on a modality switch. In conclusion, although choice of initial dialysis modality seems to be associated with equivalent outcomes among patients who have ESRD and are placed on the transplant waiting list, patients with BMI > or = 26 kg/m2 have increased 2-yr mortality associated with the selection of PD versus HD. Because the interpretation of observational data is highly affected by residual confounding and selection bias, further efforts should focus on the formation and testing of hypotheses to improve dialysis delivery.

Hydrothorax Due to Ventriculopleural Shunting in a Child with Spina Bifida on Chronic Dialysis: Third Ventriculostomy as an Alternative of Cerebrospinal Diversion

The purpose of this paper is to describe the risks of ventriculopleural shunt in patients with spina bifida and end-stage-renal-diseases (ESRD), and to describe endoscopic third ventriculostomy as an alternative for the combination of cerebrospinal shunt and dialysis modality. We report a 16-year-old boy with spina bifida on chronic dialysis with a massive unilateral hydrothorax and respiratory distress complicating a ventriculopleural (VPL) shunt. Two thoracocenteses were performed, draining 3200 ml of a clear fluid. The VPL shunt was removed and revised successfully to a third ventriculostomy (TVE). Peritoneal dialysis (PD) was the initial dialysis modality. After 12 months on PD, the patient was transferred to hemodialysis (HD) because of refractory peritonitis. Hydrothorax developed while the patient was on PD, reaching its maximum 2 months after the transference to HD. To our knowledge there has been no other report of ventriculopleural (VPL) shunt failure, and endoscopic TVE, as a cerebrospinal fluid (CSF) diversion alternative in patients on chronic dialysis.

Impact of initial dialysis modality and modality switches on Medicare expenditures of end-stage renal disease patients

The number of end-stage renal disease (ESRD) enrollees and Medicare expenditures have increased dramatically. Pathways and associated Medicare expenditures in ESRD treatment need to be examined to potentially improve the efficiency of care. This study examines the impact of initial dialysis modality choice and subsequent modality switches on Medicare expenditure in a 3-year period. The Dialysis Morbidity and Mortality Study Wave 2 data by the United States Renal Data System (USRDS) is used along with the USRDS Core CD and USRDS claims data. A total of 3423 incident dialysis patients (approximately equal number of peritoneal dialysis and hemodialysis) were included in the analysis. Unadjusted average annual Medicare expenditure (in 2004 dollars) for peritoneal dialysis as first modality was 53,277 dollars(95% CI 50,626 dollars-55,927 dollars), and 72,189 dollars (95% CI 67,513 dollars-76,865 dollars) for hemodialysis. Compared to "hemodialysis, no switch" subgroup, "peritoneal dialysis, no switch" had a significantly lower annual expenditure (44,111 dollars vs. 72,185 dollars) (P < 0.001). "Peritoneal dialysis, with at least one switch" and "hemodialysis, with at least one switch" had a lower or similar annual expenditure of 66,639 dollars and 72,335 dollars, respectively. After adjusting for patient characteristics, annual Medicare expenditure was still significantly lower for patients with peritoneal dialysis as the initial modality (56,807 dollars vs. 68,253 dollars) (P < 0.001). Similarly, compared to "hemdialysis, no switch" subgroup, "peritoneal dialysis, no switch" and "peritoneal dialysis, with at least one switch" had a significantly lower total expenditure. Further analysis showed that time-to-first switch also independently impacted total expenditure. Initial modality choice (peritoneal dialysis or hemodialysis) and subsequent modality switches had significant implications for Medicare expenditure on ESRD treatments.

Patients with Fabry disease on dialysis in the United States

: Fabry disease results from an X-linked deficiency of lysosomal alpha-galactosidase A and is a rare cause of end-stage renal disease. Little is known about the characteristics of patients with Fabry disease that initiate dialysis in the United States, although data from Europe suggests these individuals have a poor survival. : Using the United States Renal Disease System database, we first studied in detail 42 Fabry patients who initiated dialysis between April 1995 (following the introduction of the new detailed HCFA 2728 form) and July 1998. To examine crude survival in a larger cohort, 95 Fabry patients were studied who initiated dialysis between 1985 and 1993, similar to the European Registry. Diabetic and non-diabetic controls matched by age, gender, race, year of dialysis initiation, and initial dialysis modality were examined for comparison. : During the years 1995 to 1998, the mean age of Fabry patients that initiated dialysis was 42 years, 83% were Caucasian, and 10% were African American. Despite the X-linked inheritance of Fabry disease, 12% of Fabry patients on dialysis were female. At initiation of dialysis mean serum albumin and creatinine were significantly higher and mean body mass index was significantly lower among Fabry patients, but mean glomerular filtration rate was similar to controls. Fabry patients tended to have a lower three-year survival compared to non-diabetic controls, but the results were not significantly different. In a larger cohort of Fabry patients who initiated dialysis between 1985 and 1993, the three-year survival of Fabry patients was significantly lower than non-diabetic controls: 63% (95% CI, 50 to 75%) versus 74% (95% CI, 67 to 80%; P=0.03). : End-stage renal disease is associated with significant morbidity and mortality among patients with Fabry disease. Recent evidence that progression of Fabry disease may be attenuated by enzyme replacement therapy necessitates increased awareness of Fabry disease and its comorbidities.

Quality of life over time in dialysis: The Netherlands Cooperative Study on the Adequacy of Dialysis

Information on the longitudinal quality of life (QL) of patients treated by different dialysis modalities is lacking. Therefore, we performed a prospective cohort study on the QL over time in hemodialysis (HD) and peritoneal dialysis (PD) patients. New chronic dialysis patients from 13 Dutch dialysis centers were consecutively included. The patients' self-assessment of QL was measured with the SF-36 form at 3, 6, 12, and 18 months after the start of dialysis treatment. Out of 230 patients who completed the QL questionnaire at least once, 139 patients stayed on their initial dialysis modality, 26 patients switched dialysis modality, 35 patients were transplanted, 28 patients died, and two patients had a recovery of renal function. The QL of patients who died during the study period was considerably worse at baseline and worsened at a faster rate than in the other patient groups. In patients who stayed on their initial dialysis modality, the physical QL decreased over time, whereas the mental QL tended to remain stable. After an adjustment for the initial value of QL and comorbidity, a consistently favorable effect of HD on physical QL over time was found compared with PD, whereas mental QL values remained similar. Parameters of adequacy of dialysis were not associated with QL over time. This prospective cohort study shows that physical QL over time in HD patients is better than in PD patients.