Nurse-assisted Peritoneal Dialysis Research Articles

Sex disparities in the utilization of nurse-assisted peritoneal dialysis: a mediation analysis using data from the REIN registry.

This study was carried out to evaluate the association between patient sex and the proportion of nurse-assisted peritoneal dialysis (PD) at dialysis initiation and to explore whether sex disparities in nurse-assisted PD utilization was explained by predialysis care and/or by social deprivation using mediation analysis. This was a retrospective study using data from the Renal Epidemiology and Information Network (REIN) registry linked to the French National Healthcare Database (SNDS) of incident patients between 1 January 2017 and 30 June 2018. A regression logistic was used for statistical analysis. A mediation analysis explored the direct effect of sex on nurse-assisted PD proportion and the indirect effect through the European Deprivation Index (EDI), and the number of general practitioner (GP) and nephrologist visits before dialysis initiation. Among 1706 patients on PD, there were 637 women (37.3%) and 1069 men (62.7%). Nurse-assisted PD proportion was 332/610 (54.4%) for women vs 464/1036 (44.8%) for men. In the multivariable analysis women were more likely to be treated by nurse-assisted PD {odds ratio (OR) 1.92 [95% confidence interval (CI) 1.46-2.52]}. Nurse-assisted PD was associated with the median number of GP visits [OR 1.44 (95% CI 1.11-1.86)] and with the median number of nephrologist visits [OR 0.59 (95% CI 0.46-0.76)]. The mediation analysis showed a direct effect of sex on nurse-assisted PD [OR 1.90 (95% CI 1.80-2.01)] and an indirect effect through the median number of GP visits [OR 1.05 (95% CI 1.04-1.06], the median number of nephrologist visits [OR 1.02 (95% CI 1.02-1.03)] and quintile 5 of the EDI [OR 1.03 (95% CI 1.02-1.03)]. Women were more frequently treated by nurse-assisted PD than men. Differences between women and men in predialysis care and social deprivation could explain the greater utilization of nurse-assisted PD among women.

Are sex differences in the outcome of peritoneal dialysis explained by nurse assistance? A cohort study with data from the Registre de Dialyse Péritonéale de Langue Française.

We aimed to evaluate sex differences in peritoneal dialysis (PD) outcomes and to explore direct and indirect effects of nurse-assisted PD on outcomes. This was a retrospective study using data from the Registre de Dialyse Péritonéale de Langue Française of incident PD patients between 2005 and 2016. Cox proportional hazards modelling was used to analyse transfer to haemodialysis (HD), death, PD failure, peritonitis and renal transplantation. Mediation analyses with a counterfactual approach were carried out to evaluate natural direct and indirect effects of sex on transfer to HD and peritonitis, with nurse-assisted PD as a mediator a priori. Of the 14 659 patients included, there were 5970 females (41%) and 8689 males (59%). Women were more frequently treated by nurse-assisted PD than men [2926/5970 (49.1%) versus 3357/8689 (38.7%)]. In the multivariable analysis, women had a lower risk of transfer to HD [cause-specific hazard ratio {cs-HR} 0.82 {95% confidence interval (CI) 0.77-0.88}], death [cs-HR 0.90 (95% CI 0.85-0.95)], peritonitis [cs-HR 0.82 (95% CI 0.78-0.87)], PD failure [cs-HR 0.86 (95% CI 0.83-0.90)] and a lower chance of undergoing transplant [cs-HR 0.83 (95% CI 0.77-0.90)] than men. There was a direct effect of sex on the risk of transfer to HD [cs-HR 0.82 (95% CI 0.82-0.83)], with an indirect effect of nurse-assisted PD [cs-HR 0.97 (95% CI 0.96-0.99)]. Nurse-assisted PD had no indirect effect on the risk of peritonitis. Our results suggest that compared with men, women have a lower risk of both transfer to HD and peritonitis. Mediation analysis showed that nurse assistance was a potential mediator in the causal pathway between sex and transfer to HD.

Impact of assistance on peritonitis due to breach in aseptic procedure in diabetic patients: A cohort study with the RDPLF data.

Diabetic patients often have physical impairment that could lead to manipulation errors in peritoneal dialysis (PD) and touch contamination. Nurse assistance in diabetic PD patients is known to help prevent peritonitis. We made the hypothesis that this lower risk of peritonitis was observed thanks to prevention of breach in aseptic procedure. We evaluated the impact of nurse-assisted PD on specific causes of peritonitis, especially on peritonitis due to a breach in aseptic procedure. This was a retrospective observational study of the data from the French Language Peritoneal Dialysis Registry. All diabetic patients older than age 18 years starting PD in France between 1 January 2012 and 31 December 2015 were included in the study. The event of interest was the first peritonitis event due to a breach in aseptic procedure. Death, kidney transplantation and peritonitis due to another mechanism were considered as competing events. We examined the association of the covariates with all the possible outcomes using a subdistribution hazard model developed for survival analysis in the presence of competing risks. Four thousand one hundred one diabetic patients incident in PD were included in the study. At least one peritonitis event occurred in 1611 patients over the study period. A breach in aseptic procedure was reported in 441/1611 cases (27.3%): 209/575 (36.3%) in the self-care PD group, 56/217 (25.8%) in the family-assisted PD group and 176/819 (21.5%) in the nurse-assisted PD group. Both nurse and family assistance were associated with a lower risk of peritonitis due to breach in aseptic procedure in bivariate analysis. After adjustment on age, modified Charlson index, sex and diabetic nephropathy, patients treated by nurse-assisted PD (subdistribution hazard ratio (sd-HR) 0.52, 95% confidence interval (CI) 0.40-0.67) and those treated by family-assisted PD (sd-HR 0.70, 95% CI 0.51-0.95) had a lower likelihood of peritonitis due to a connection error compared to self-care PD in multivariate analysis. The modality of assistance was not associated with other causes of peritonitis in the multivariate analysis. While both nurse-assisted PD and family-assisted PD were associated with lower risk of peritonitis due to a breach in aseptic procedure compared to self-care PD in our study, the protective effect was greater with nurse assistance.

Assisted peritoneal dialysis and transfer to haemodialysis: a cause-specific analysis with data from the RDPLF.

Technique failure, defined as death or transfer to haemodialysis (HD), is a major concern in peritoneal dialysis (PD). Nurse-assisted PD is globally associated with a lower risk of transfer to HD. We aimed to evaluate the association between assisted PD and the risk of the different causes of transfer to HD. This was a retrospective study using data from the French Language PD Registry of patients on incident PD from 2006 to 2015. The association between the use of assisted PD and the causes of transfer to HD was evaluated using survival analysis with competing events in unmatched and propensity score-matched cohorts. The study included 11 093 incident PD patients treated in 123 French PD units. There were 4273 deaths, 3330 transfers to HD and 2210 renal transplantations. The causes of transfer to HD were inadequate dialysis (1283), infection (524), catheter-related problems (334), social issues (250), other causes linked to PD (422), other causes not linked to PD (481) and encapsulating peritoneal sclerosis (6). Nurse-assisted PD patients were older and more comorbid. Assistance by nurse was associated with a higher risk of death [cause-specific hazard ratio (cs-HR) 2.49, 95% confidence interval (CI) 2.26-2.74], but with a lower risk of transfer to HD [subdistributionHR (sd-HR) 0.68, 95% CI 0.62-0.76], especially due to inadequate dialysis (cs-HR 0.83, 95% CI 0.75-0). The lower risk of transfer to HD associated with nurse assistance should encourage decision makers to launch reimbursement programmes in countries where it is not available.

Trends in assisted peritoneal dialysis over the last decade: a cohort study from the French Peritoneal Dialysis Registry.

BackgroundThere is limited information available on the use of assisted peritoneal dialysis (PD) over time and the impact of economic incentives on its utilization. The aim of this study was to describe the trends in assisted PD utilization and the type of assistance provided. We wanted to estimate if an economic incentive implemented in 2011 in France was associated with an increase in the utilization of nurse-assisted PD.MethodsThis retrospective, multicentre study, based on data from the French Language Peritoneal Dialysis Registry, analysed 11 987 patients who initiated PD in France between 1 January 2006 and 31 December 2015. Adjusted Cox regression with robust variance was used to examine the initiation of assisted PD, both nurse-assisted and family-assisted, accounting for the nonlinear impact of the PD starting time.ResultsThere were 6149 (51%) incident patients on assisted PD, 5052 (82%) on nurse-assisted PD and 1097 (18%) on family-assisted PD over the study period. In the adjusted analysis, calendar time was associated with the assisted PD rate: it declined from 2008 until 2013 before flattening out and then it increased after 2014. Nurse-assisted PD utilization increased significantly after 2012, whereas family-assisted PD utilization decreased linearly over time (prevalence ratio = 0.94, 95% confidence interval 0.92–0.97).ConclusionsThe assisted PD rate decreased until 2013, mainly because of a decline in family-assisted PD. The uptake in nurse-assisted PD observed from 2013 reflects the effect of an economic incentive adopted in late 2011 to increase PD utilization.

Assessment for Assisted Peritoneal Dialysis by Peritoneal Dialysis Nurses: Results of a Cohort Study

Background: Selection of patients for assisted peritoneal dialysis (PD) is based on the nurse’s assessment of the patient. There is no data available about the nurse’s assessment of the PD patient at the initiation of PD to estimate the need for assisted PD at the national level. This study was carried out to evaluate the association between the nurse’s subjective assessment of the patient’s inability to be treated by self-care PD, the nurse evaluation of the patient disabilities and the utilization of nurse or family assisted PD. Methods: This was a retrospective study of patients starting PD between July 1, 2010 and 2015 and registered in the nurse section of the French Language PD Registry (RDPLF). Poisson regression and a linear regression model with a robust variance estimator were used for the statistical analysis to determine relative risks (RRs) and risk differences (RDs). Results: Of 4,101 PD patients, 403 were treated by family assisted PD, and 1,695 were treated by nurse-assisted PD. In the multivariate analysis, the nurse’s subjective assessment of the patient’s inability to be treated by self-care PD was associated with nurse-assisted PD (5.40 [4.58–6.35], 67% [64–70%]) and family assisted PD (11.11 [8.49–14.56], RD 62% [57–67%]). Nurse-assisted PD and family assisted PD were associated with functional impairment (RR 1.25 [95% CI 1.16–1.36], RD 14% [95% CI 10–19%] and RR 2.02 [95% CI 1.69–2.41], RD 27% [95% CI 20–34%] respectively), cognitive dysfunction (RR 1.23 [95% CI 1.15–1.32], RD 15% [95% CI 11–18%] and RR 1.73 [95% CI 1.39–2.16], RD 12% [95% CI 7–18%] respectively) and deafness (RR 1.10 [95% CI 1.04–1.16], RD 8% [95% CI 5–11%] and RR 1.46 [95% CI 1.22–1.74], RD 10% [95% CI 6–14%] respectively). Conclusion: Our results showed that the nurse’s subjective assessment of the patient’s inability to be treated by self-care PD and the patient’s disabilities were strongly associated with the utilization of nurse- and family assisted PD.

Impact of Assisted Peritoneal Dialysis Modality on Outcomes: A Cohort Study of the French Language Peritoneal Dialysis Registry

Background: Patients on peritoneal dialysis (PD) can be assisted by a nurse or a family member and treated either by automated PD (APD) or continuous ambulatory PD (CAPD). The aim of this study was to evaluate the effect of PD modality and type of assistance on the risk of transfer to haemodialysis (HD) and on the peritonitis risk in assisted PD patients. Method: This was a retrospective study based on data from the French Language PD Registry. All adults starting assisted PD in France between 2006 and 2015 were included. Events of interest were transfer to HD, peritonitis and death. Cox regression models were used for statistical analysis. Results: Among the 12,144 incident patients who started PD in France during the study period, 6,167 were assisted. There were 5,060 nurse-assisted and 1,095 family-assisted PD patients. Overall, 5,171 were treated by CAPD and 996 by APD. In multivariate analysis, CAPD, compared to APD, was not associated with the risk of transfer to HD (cause specific hazard ratios [cs-HR] 0.96 [95% CI 0.84–1.09]). Patients on nurse-assisted PD had a lower risk of transfer to HD than family assisted PD patients (cs-HR 0.85 [95% CI 0.75–0.97]). Neither PD modality nor type of assistance were associated with peritonitis risk. Conclusions: In assisted PD, technique survival was not associated with PD modality. Nurse-assisted patients had a lower risk of transfer to HD than family assisted patients. Peritonitis risk was not influenced either by PD modality, or by type of assistance. Both APD and CAPD should be offered to assisted-PD patients.

Factors associated with nurse assistance among peritoneal dialysis patients: a cohort study from the French Language Peritoneal Dialysis Registry.

No information is available regarding nurse-assisted peritoneal dialysis (PD) in non-elderly subjects. This study was carried out to estimate the rate of nurse-assisted PD among non-elderly patients and to assess which individual and centre factors were associated with nurse-assisted PD. The other objective was to estimate the magnitude of the centre effect on the utilization of nurse-assisted PD using hierarchical modelling. This was a retrospective study based on data from the French Language Peritoneal Dialysis Registry. Patients incident on PD > 18 and < 65 years of age were included. There were 2269 incidents of PD initiation between January 2008 and December 2012 in 127 PD centres with 114 (5%) on family-assisted PD and 272 (12%) on nurse-assisted PD. At the individual level, compared with autonomous patients, nurse assistance was associated with age {odds ratio [OR] 1.79 [95% confidence interval (CI) 1.51-2.13]}, gender [OR 0.47 (95% CI 0.35-0.64)], comorbidities and underlying nephropathy. There was significant heterogeneity between centres in the nurse assistance utilization (variance of random effect 0.12). At the centre level, the type of centre, centre experience, centre organization and private nurse density were not associated with nurse-assisted PD. The rate of nurse-assisted PD among non-elderly patients was 12%. There was a significant centre effect in the utilization of nurse assistance that was not explained by the centres' characteristics. Nurse-assisted PD utilization in non-elderly patients is associated with patient characteristics and also with centre practices.

Is Peritonitis Risk Increased in Elderly Patients on Peritoneal Dialysis? Report from the French Language Peritoneal Dialysis Registry (RDPLF).

♦ This study was carried out to examine whether or not elderly patients on peritoneal dialysis (PD) had an increased risk of peritonitis. ♦ This was a retrospective cohort study based on data from the French Language Peritoneal Dialysis Registry. We analyzed 8,396 incident patients starting PD between January 2003 and December 2010. The end of the observation period was 31 December 2012. Patients were separated into 2 age groups: up to 75 and over of 75 years old. ♦ Among 8,396 patients starting dialysis there were 3,173 patients older than 75. When using a Cox model, no association was found between age greater than 75 years and increased risk of peritonitis (hazard ratio [HR]: 0.97 [0.88 - 1.07]). Diabetes (HR: 1.14 [1.01 - 1.28] and continuous ambulatory PD (HR: 1.13 [1.04 - 1.23]) were significantly associated with a higher risk of peritoneal infection whereas nurse-assisted PD was associated with a lower risk of peritonitis (HR: 0.85 [0.78 - 0.94]. In the analysis restricted to the 3,840 self-care PD patients, there was no association between age older than 75 years and risk of peritonitis. ♦ The risk of peritonitis is not increased in elderly patients on PD in a country where assisted PD is available.

Effect of assistance on peritonitis risk in diabetic patients treated by peritoneal dialysis: report from the French Language Peritoneal Dialysis Registry.

Diabetic patients treated by peritoneal dialysis (PD) have been reported to be at an increased risk of peritonitis. This has been attributed to impairment in host defense, visual impairment, disability and muscle wasting, which could compromise ability to safely perform catheter connections. This study aimed to evaluate whether assisted PD is associated with a lower risk of peritonitis in diabetic patients. This was a retrospective study based on data from the French Language Peritoneal Dialysis Registry. We included diabetic patients starting PD between 1 January 2002 and 31 December 2012. The end of the observation period was 31 December 2013. Using complementary regression analysis (Fine and Gray, Hurdle models), we assessed the relationship between peritonitis occurrence, peritonitis number over time and the type of assisted PD. Of the 3598 diabetic patients, there were 2040 patients on nurse-assisted PD. These patients were older, more comorbid and more frequently on continuous ambulatory peritoneal dialysis (CAPD). In the multivariate analysis, nurse assistance was associated with a reduced risk of peritonitis in the Fine and Gray [subdistribution hazard ratio: 0.78 (95% confidence interval, CI, 0.68-0.89)] and in the first component of the Hurdle models [rate ratio: 0.82 (95% CI 0.71-0.93)], but not a lower incidence of peritonitis after an initial episode [rate ratio: 0.82 (95% CI 0.95-1.38)]. Transplant failure, glomerulonephritis and CAPD were associated with an increased risk. In France, nurse-assisted PD is associated with a lower risk of peritonitis in diabetic patients treated by PD but not a lower incidence of peritonitis.

Can peritoneal dialysis be applied for unplanned initiation of chronic dialysis?

Late referral of patients with chronic kidney disease (CKD) and unforeseeable deterioration of residual renal function in known CKD patients remain a major problem leading to the need of unplanned start on chronic dialysis without a mature access for dialysis. In most centres worldwide, these patients are started on haemodialysis (HD) using a temporary tunnelled central venous catheter (CVC) for access. However, during the last decade, increasing clinical experience with unplanned start on peritoneal dialysis (PD) right after PD catheter implantation has been published. Key studies are reviewed in the present paper, and the results seem to indicate that compared with patients starting PD in a planned setting with peritoneal resting after PD catheter implantation, patients starting unplanned PD have an increased risk of mechanical complications but apparently no increased risk of infectious complications. In contrast, patients starting unplanned HD using a temporary CVC have an increased risk of both mechanical and infectious complications when compared with patients starting planned HD using an arterio-venous fistula or a permanent CVC. Regarding clinical outcome in terms of survival, unplanned PD seems to be at least as safe as unplanned HD. Combining the unplanned PD programme with a nurse-assisted PD programme is crucial in order to offer the patient a real opportunity to choose a home-based dialysis option. In conclusion, unplanned start on PD seems to be a feasible, safe and efficient alternative to unplanned start on HD for the late referred patient with end-stage renal disease and urgent need for dialysis.