Peritoneal Dialysis Group Research Articles

P0319DEPRESSIVE BURDEN, QUALITY OF LIFE AND CAREGIVER BURDEN IN END STAGE RENAL DISEASE - A PARADIGMATIC SHIFT IN HOLISTIC MANAGEMENT

Abstract Background and Aims Depressive illness is not only common in patients of End Stage Renal Disease (ESRD) but also an independent risk factor for morbidity and mortality. The relation between depressive illness, Quality of Life and caregiver burden in this vulnerable group is complex. We attempted to study these 3 important psychosocial domains in patients of ESRD on hemodialysis, peritoneal dialysis as well as those ESRD patients who were not on any dialysis yet Method A cross sectional analytical comparative controlled design was done to compare 3 domains of depressive burden, quality of life and caregiver burden in 3 group of patients – ESRD patients on hemodialysis, ESRD patients on peritoneal dialysis and ESRD patients not on any dialysis Statistical methods used - χ2 statistic or Fisher‘s exact test for categorical variables and comparison of group means. ANOVA was used for continuous variables where more than 3 groups were compared. Correlational analysis done using Spearman’s correlation coefficient . A p-value of <0.05 was considered significant. SPSS 20.0 was used Results Depressive symptoms were present significantly across all 3 groups of ESRD. Depressive disorder was significantly higher in the Hemodialysis group (HD) as compared to peritoneal dialysis (PD) group( p=0.038). Mean QOL was significantly higher for PD. Caregiver burden was higher in the HD group. The study brought out the huge burden of depressive symptoms and depressive illness in patients on ESRD across all 3 group of patients and the significantly higher burden of depressive illness and lower QoL and higher caregiver burden in the hemodialysis group. This assumes significance because the majority of our ESRD patients are on HD Conclusion This depressive burden is the hidden factor behind poor Quality of Life as well as poor overall satisfaction as well as treatment outcome in our patients of ESRD whether or not on dialysis. Apart from the inherent factors related to the illness or the type of dialysis, sociodemographic factors seem to play a role in QoL and CG burden in the hemodialyis group. To address this hidden depressive burden comprehensively, we recommend closer cooperation between nephrologist, psychiatrist and psychosocial workers to improve the overall treatment outcome in ESRD patients.

P1161CUTANEOUS MICROCIRCULATORY DYSFUNCTION IN PERITONEAL DIALYSIS PATIENTS

Abstract Background and Aims Microvascular impairment is an early step in cardiovascular disease (CVD), the major cause of morbidity and mortality in patients with CKD. Changes in skin microvascular reactivity have been shown to reflect more widespread changes in the systemic and coronary microcirculation. Microvascular function is attenuated by advancing age and conditions that commonly coexist with CKD such as diabetes and hypertension. We investigated whether skin microvascular reactivity is impaired in peritoneal dialysis (PD) patients compared with healthy controls and whether this impairment is independent of comorbidity. Method Forearm skin vasculature was examined in 27 healthy controls, 27 patients on PD and 27 controls matched to the PD patients for age, gender, diabetes and previous CV events. Microvascular function was assessed using laser Doppler flowmetry in combination with post-occlusive reactive hyperaemia (a test of generalised microvascular function) and iontophoretic application of acetylcholine (ACh) and sodium nitroprusside (SNP) to investigate endothelium dependant and non-endothelium dependant vasodilation respectively. Results Peak post-occlusive flow was lower in the PD patients than in both the healthy controls and the co-morbidity matched group; 90.45 AU (60.9-128.35) in healthy controls, 73AU (58.8-134.4) in matched controls and 56.95AU (45.1-89.8) in PD patients (p=0.0239 healthy controls versus patients, p=0.0373 matched controls versus patients). SNP-mediated vasodilatation was statistically lower in the PD group compared with healthy controls (p= 0.016), ACh response was lower but did not reach statistical significance (p= 0.076). ACh and SNP-mediated vasodilatation trended towards being lower in PD patients than matched controls but did not reach statistical significance. Conclusion The PD patients were characterised by a generalised dysfunction of the skin microcirculation compared with healthy controls and controls matched for factors known to affect the microcirculation. This appears to be the result of impaired endothelium dependant and independent vasodilatory mechanisms.

Biochemical Indicators of Malnutrition in Children with Chronic Kidney Disease on Peritoneal Dialysis, Hemodialysis and Post-Transplant Kidney

Abstract Objectives To demonstrate differences in the profile of biochemical indicators of nutritional status in children with End-stage renal disease (ESRD) between peritoneal dialysis (PD), hemodialysis (HD), and renal transplantation (RT). Methods Analytical cross-sectional study. A total of 130 children and adolescents between 6 and 18 years of age with ESRD were included: 49 children in RT, 33 in PD, and 48 in HD. The biochemical indicators (hemoglobin, glucose, albumin, total cholesterol, and triglycerides) and anthropometric indicators of nutritional status were obtained. ANOVA, T-student, and Pearson correlation were performed. For nonparametric variables, Chi-square, U-Mann Whitney, Kruskal-Wallis, and odds ratio were used. Results The frequency of hypoalbuminemia was higher in the PD group than in the RT group [OR = 56.4 (6.9, 459) P < 0.001] and the HD group [OR = 10.08 (3.1, 319) P < 0.001]. Anemia was higher in the HD group compared with the RT group [OR = 4.9 (2.1, 11.2) P < 0.001] and the PD group [OR = 3.0 (1.3, 7.7), P = 0.02]. Cholesterol serum concentration was higher in the PD group compared to the RT group [OR = 27.4 (3.3, 225), P < 0.01] and the HD group [OR = 26.2 (3.2, 215), P < 0.001]. Patients in the PD group had a higher risk of hypertriglyceridemia than the RT group [OR = 5.5 (1.9, 15.7), P = 0.002] and the HD group [OR = 2.3 (1.1, 5.4), P = 0.04]. Albumin correlated with tricipital skinfold and mid-upper arm circumference (MUAC) in the RT group; with subscapular skinfold (SSF) in the HD group; and with height, SSF, and MUAC in PD group. Conclusions There are substantial differences in the biochemical indicators of nutritional status depending on the renal substitution program. Funding Sources Project supported by the National Council of Science and Technology of Mexico.

A comparison of the risk of acute myocardial infarction in patients receiving hemodialysis and peritoneal dialysis: A population-based, propensity score-matched cohort study

Background and aimsAcute myocardial infarction (AMI) remains the major cause of morbidity and mortality in the dialysis population. Traditional cardiovascular (CV) risk factors are unable to fully account for the high incidence of AMI in the dialysis population. In this study, we investigated whether dialysis modalities could be one of the uremia-specific risk factors for AMI. MethodsUsing the National Health Insurance Research Database, we recruited all incident dialysis patients from the period January 1, 1998 to December 31, 2010. The propensity score matching method was applied to form the matched pairs of hemodialysis (HD) and peritoneal dialysis (PD) patients. Incidence rate (IR), cumulative incidence rate (CIR) and multivariable subdistribution hazards models were employed to compare the risk of AMI in the HD and PD groups. ResultsOf the 86,215 incident dialysis patients, 5,513 matched pairs of HD and PD patients were identified. The HD patients had a higher IR of AMI than the PD patients (9.71 vs. 8.35 per 1000 patient-years, respectively, p = 0.01). The CIR was also higher in the HD patients than in the PD patients (0.09 vs. 0.05), especially 4 years after dialysis therapy was initiated (p = 0.04). In the subdistribution hazards models, HD was still significantly associated with a higher risk of developing AMI (adjusted hazard ratio:1.30, 95% confidence interval:1.02–1.65). The results remained unchanged in various stratifications as well as in the analysis of the unmatched cohorts. ConclusionsCompared to PD, HD was significantly associated with higher risk of developing AMI, especially after 4 years since dialysis was initiated. Prevention and routine surveillance programs for AMI should be individualized according to dialysis modalities and vintage.

Association between initial dialytic modalities and the risks of mortality, infection death, and cardiovascular events: A nationwide population-based cohort study

To date, few studies have been conducted to pairwise compare the prognosis of peritoneal dialysis (PD), unplanned PD, and unplanned hemodialysis (HD). We analyzed longitudinal data from Taiwan’s National Health Insurance Research Database. We included 45,165 patients whose initial dialytic modality was PD or unplanned HD between January 1, 2001 and December 31, 2013. We divided the patients into three groups according to their initial dialytic modalities. The primary outcomes were all-cause mortality and death from infection during 1-year follow up. The risks of all-cause mortality and infection death were higher in the unplanned PD group than in the planned PD group (hazard ratio [HR] 1.43, 95% confidence interval [CI] 1.28–1.60; HR 1.54, 95% CI 1.32–1.80). Likewise, the risks of all-cause mortality and infection death were higher in the unplanned HD group (HR 1.64, 95% CI 1.48–1.82; HR 1.85, 95% CI 1.61–2.13). Furthermore, the risks of all-cause mortality and infection death were also higher in the unplanned HD group than in the unplanned PD group (HR 1.15, 95% CI 1.07–1.23; HR 1.20, 95% CI 1.09–1.32). In conclusion, our study demonstrates that patients whose initial modality was planned PD or unplanned PD may have better clinical outcomes than those whose initial modality was unplanned HD.

The relationship between lymphocyte subsets, nutritional status and tuberculin reactivity in continuous ambulatory peritoneal dialysis and hemodialysis patients

AimSkin test anergy is common in patients with uremia and during maintenance hemodialysis treatment. However, up to date only one study concerning skin test in peritoneal dialysis patients has focused on the issue. Our cross-sectional controlled study was conducted to analyze the correlation of purified protein derivative (PPD) test response with demographical features, nutritional parameters and the distribution of peripheral blood lymphocyte subsets in peritoneal dialysis and hemodialysis patientsPatients and methodsStable 30 hemodialysis (HD) patients (16 men, 14 women) and 30 continuous ambulatory peritoneal dialysis (PD) patients (17 men, 13 women) were included. Thirty healthy cases (15 men, 15 women) with a mean age of 32.4 ± 9.4 constituted the control group.ResultsIn the HD group, 14 patients (46.6%) were PPD positive, and ın the PD group 16 patients (53.3%) were PPD positive. In the PPD-positive HD patients 64.2% (9/14), and in the PPD-positive PD patients 62.4% (10/16) had an induration of 10 mm or greater. In the control group, 21 of 30 patients (70%) were PPD positive. Comparison of both HD and PD groups with the control group showed significant differences in PPD reactivity (p < 0.01). Albumin levels were significantly high in the control groups (p < 0.01), and cholesterol levels were significantly high in the PD and the control groups (p < 0.05). Transferrin levels were significantly high in the PD (p < 0.01). The lymphocyte counts were significantly high in the control group compared to the HD patients (p < 0.05). The lymphocyte subset percentages CD19 were high in the control groups (p < 0.05), and CD16/56 was significantly high in the PD groups (p < 0.05). All the parameters were also similar between PPD-positive and -negative same groups.ConclusionThe prevalence of PPD positivity was lower in the PD and HD groups. The PPD test responses were not related to the peripheral lymphocyte counts, subsets and malnutrition parameters.

Changes in mortality hazard of the Korean long-term dialysis population: The dependencies of time and modality switch.

Many studies have compared patient survival outcome between hemodialysis (HD) and peritoneal dialysis (PD); however, time-varying risks of dialysis modality have been rarely investigated. This study aimed to investigate dialysis modality switch and its association with the survival outcome in the Korean population. Data from the Korean Society of Nephrology were used. A total of 21,840 incident dialysis patients who started dialysis in or after 2000 were analyzed. For the survival analysis, both proportional and non-proportional hazard assumptions were applied. For the modality switch, time-varying covariate Cox regression was applied. During the median follow-up of 8 years, PD group showed increased adjusted hazard ratio (HR) of 1.248 (95% CI 1.071-1.454, p = 0.004) for mortality. Interaction of PD status with female sex was significant with an HR of 1.080 (95% CI 1.000-1.165, p = 0.050). Dialysis modality switch was associated with increased HR of 1.094 (95% CI 1.015-1.180, p = 0.019), albeit switch from PD to HD did not show significant HR until 6 years. Interestingly, time-varying risk analysis showed a decreased HR of PD after 10 years in the non-switcher group, which was consistent in patients with high traditional risk factors (with diabetes, elderly). PD was associated with increased HR of mortality in the first 8 years, then it was associated with decreased HR of mortality after 10 years. Dialysis modality switch was associated with increased mortality risk, but switch from PD to HD within 6 years did not show significant hazard of mortality.

Urgent-start peritoneal dialysis in chronic kidney disease patients: A systematic review and meta-analysis compared with planned peritoneal dialysis and with urgent-start hemodialysis

An increasing number of studies have focused on whether peritoneal dialysis (PD) can be used for the urgent initiation of dialysis in patients with chronic kidney disease (CKD). We performed this systematic review and meta-analysis to evaluate the feasibility and safety of urgent-start PD compared with those of planned PD and urgent-start hemodialysis (HD) in this population. PubMed, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), clinicaltrials.gov, and China National Knowledge Infrastructure (CNKI) were searched for relevant studies. Conference abstracts were also searched in relevant websites. The meta-analysis was performed using RevMan 5.3 software. A total of 15 trials involving 2426 participants were identified. The quality of the included studies was fair, but the quality of evidence was very low. Unadjusted meta-analysis showed that urgent-start PD had significantly higher mortality than planned PD, while adjusted meta-analysis did not show a significant difference. Higher incident of leakage and catheter mechanical dysfunction were observed in urgent-start PD. However, peritonitis, exit-site infection, or PD technique survival were comparable between urgent-start and planned PD. The all-cause mortality was comparable in urgent-start PD and urgent-start HD. Bacteremia was significantly lower in the urgent-start PD group than with urgent-start HD. Based on limited evidences, PD may be a viable alternative to HD for CKD patients requiring urgent-start dialysis. Because of the inconsistent results and the low quality of evidence, a definitive conclusion could not be drawn for whether urgent-start PD was comparable with planned PD. Therefore, high-quality and large-scale studies are needed in the future.

The effects of dialysis modalities on sexual hormone levels in male patients

Introduction: Low testosterone level is association with low quality of life and cardiovascular risk factors. The dialysis modality effects on testosterone levels remain unclear. To investigate the haemodialysis (HD) and peritoneal dialysis (PD) effects on male sexual hormones. Material and Method: Serum total testosterone (TT), free testosterone (FT), follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin (PRL) and sex hormone-binding globulin (SHBG) were investigated. Serum TT below 3 ng/ml was considered a low TT. Sociodemographic data and an Index of Independence in Activities of Daily Living were recorded. Results: This study included adult male HD (n = 71) and PD (n = 24) patients. Age and dialysis duration were similar between groups. Serum TT and FT levels were significantly higher in the PD group (p = 0.01 and p = 0.05, respectively). There were no differences between the HD and PD groups with regard to SHBG, FSH, LH or PRL levels (p = 0.353, p = 0.858, p = 0.410 and p = 0.410, respectively). The number of patients who were capable of performing Index of Independence in Activities of Daily Living was higher in the PD group (p = 0.033) and with normal TT levels (p = 0.027). Binary regression analysis showed more favourable effects in the PD group on testosterone levels (OR = 4.659; 1.477–14.704 95% CI Exp B). Conclusion: PD has favourable effects on testosterone levels compared to HD. Mental and physical well being resulting from PD and its technique affect TT levels.

Comparison Of Monocyte / HDL Ratio In Routine Hemodialysis And Peritoneal Dialysis Patients

Objective: Chronic kidney disease (CKD) is an inflammatory process. Serum proinflammatory cytokines are known to be ten times higher in patients with CKD when compared to normal population. Monocyte/High density lipoprotein (HDL) cholesterol ratio (MHR) have been shown to be a new marker of inflammation and claimed that, it may be used to predict cardiovascular events in patients with CKD. This cross-sectional study aimed to compare monocyte / HDL cholesterol ratio in patients treated with hemodialysis and peritoneal dialysis. Methods: Files of patients who have been followed up with end stage renal disease (ESRD) and have peritoneal dialysis or hemodialysis therapy in Nephrology Clinic of our hospital have been retrospectively examined. Patients were divided into two groups regarding renal replacement treatment type. Monocyte / HDL cholesterol ratio was compared between groups. IBM SPSS Statistics 22.0 (IBM Corp., NY, USA) packaged software and appropriate statistical methods were used to analyse data. Results: Monocyte / HDL cholesterol ratio was significantly higher in patients treated with hemodialysis (p= 0.028). HDL cholesterol levels were significantly higher in peritoneal dialysis group (p= 0.046). Total cholesterol, LDL cholesterol, triglyceride and VLDL cholesterol have been ascertained to be similar in both patient groups (p> 0.05). The high sensitivity CRP and sedimentation levels have been detected to be similar within the groups (p> 0.05). Conclusion: This is the first study evaluating the monocyte/HDL cholesterol ratio among renal replacement therapy modalities in our literature review. In this study, it has been shown that; monocyte/HDL cholesterol ratio were statistically higher in patients having hemodialysis than in the ones followed up with peritoneal dialysis. According to these results, it may be considered that; peritoneal dialysis may be associated with less systemic inflammation than hemodialysis.

Spatiotemporal trends and prognosis of end-stage renal disease patients with biopsy-proven immunoglobulin Anephropathy in France from 2010 to 2014.

BackgroundAlthough end-stage renal disease (ESRD) is frequently used as an outcome marker for primary immunoglobulin A nephropathy (IgAN), the clinical course after reaching ESRD is not well documented. This study examined patients’ characteristics and survival in ESRD-related biopsy-proven IgAN in France.MethodsFrench Renal Epidemiology and Information Network Registry data from 2010 to 2014 were used to analyse patients’ survival and outcome in incident ESRD patients >16 years of age with biopsy-proven primary IgAN, in comparison with other primary and secondary glomerulonephritis (GN), adult polycystic kidney disease (ADPKD) or diabetes. Multivariable survival analysis was adjusted for age, sex, time on dialysis and comorbidities.ResultsAmong 17 138 incident dialysis patients with ESRD, IgAN (242.8/10 000 dialysis initiation) represents the most common GN related to ESRD during 2010. IgAN patients were the youngest, and had the fewest comorbidities and the highest use of peritoneal dialysis (PD) (17%). In comparison with the haemodialysis group, hazard ratios for death were not different in the preemptive transplantation group [0.46, 95% confidence interval (CI) 0.17–1.28] and in the PD group (0.77, 95% CI 0.44–1.33). Mortality rates in IgAN patients with preemptive transplantation and in those receiving dialysis waiting for transplantation were 2.9% (95% CI 0.0–5.6) and 6.7% (95% CI 0.9–12.3). Mortality rates of ADPKD patients receiving dialysis waiting for transplantation were higher (18%, 95% CI 3.1–30.6).ConclusionIgAN has the best prognosis among primary and secondary GN. IgAN patients receiving dialysis waiting transplantation seem to have a more favourable prognosis than ADPKD patients, who usually comprise the reference population. The underlying reasons for the difference in access treatment modalities should be investigated to improve survival with respect to renal disease.

Comparison of hemodialysis and peritoneal dialysis patients\u2019 dietary behaviors

BackgroundNutritional factors are associated with high mortality and morbidity in dialysis patients, and protein-energy wasting is regarded as an important one. The modality of dialysis may affect patients’ dietary behavior and nutritional status, but no study has compared the dietary behavior, nutrient intake, and nutritional adequacy of hemodialysis (HD) and peritoneal dialysis (PD) patients.MethodsFrom December 2016 to May 2017, a dietary behavior survey and Semi-quantitative Food Frequency Questionnaire (Semi-FFQ) were conducted on 30 HD patients and 30 PD patients in Ewha Womans University Mokdong Hospital, and laboratory parameters were obtained. The results of prevalent HD and PD patients were then compared.ResultsThe mean age of HD patients was higher than that of PD patients; HD: 58.5 ± 9.1 years, PD: 49.3 ± 9.7 years (p = 0.001). In the dietary behavior survey, HD patients showed more appropriate dietary behavior patterns overall than PD patients. In the dietary intake analysis with the Semi-FFQ, energy intake was significantly lower in the PD group than in the HD group due to the lower intake of carbohydrates, fat, and protein. A comparison of nutrient intake-to-recommended allowance ratio between the HD and PD groups revealed that the HD group showed higher nutrient intake than the PD group. Serum albumin and potassium levels were significantly higher in HD than in PD patients.ConclusionAccording to this study, the dietary behavior and nutritional intake of prevalent PD patients were worse than those of HD patients.

Global diastolic strain rate for the assessment of left ventricular diastolic dysfunction in young peritoneal dialysis patients: a case control study

BackgroundLeft ventricular (LV) myocardial longitudinal diastolic strain rate measured by two-dimensional speckle tracking imaging (2D-STI) was proved to have a better correlation with the LV diastolic function. We aimed to use this sensitive tool to predict LV myocardial diastolic dysfunction in young peritoneal dialysis (PD) patients with preserved LV ejection fraction (LVEF).MethodsWe enrolled 30 PD patients aged ≤60 with LVEF ≥54% and classified as normal LV diastolic function by conventional echocardiography, and 30 age- and sex-matched healthy people as the control group. The left atrial maximum volume index (LAVI), LV mass index (LVMI), LVEF, LV posterior wall thickness (LVPWT), interventricular septal thickness (IVST), peak velocity of tricuspid regurgitation (TR), peak early diastolic velocity/late diastolic velocity (by Pulsed Doppler) (E/A) and E/peak velocity of the early diastolic wave (by Pulsed-wave tissue Doppler) (E/e’) were recorded by conventional echocardiographic. Next, the average LV global longitudinal systolic strain (GLS avg) and the average LV global longitudinal diastolic strain rate (DSr avg) during early diastole (DSrE avg), late diastole (DSrA avg) and isovolumic relaxation period (DSrIVR avg) were obtained from 2D-STI. Combined them with E, the new noninvasive indexes (E/DSrE avg., E/DSrA avg. and E/DSrIVR avg) were derived.ResultsThe PD group ‘s LVEF, E/e′, TR and LAVI were in the normal range compared with the controls, and only e′ (p < 0.001) was decreased. The LVMI (p < 0.001), LVPWT (p < 0.001), IVST (p < 0.001) increased while E/A (p < 0.001) decreased. The GLS avg. (p = 0.008) was significantly decreased in PD patients compared with the controls. DSrA avg. (p = 0.006) and E/DSrE avg. (p = 0.006) were increased, while DSrE avg. (p < 0.001), DSrIVR avg. (p = 0.017) and E/DSrA avg. (p < 0.001) decreased. After the multivariable regression analysis, the correlation between DSrE and the conventional parameters including LVPWT (p < 0.001), E/A (p < 0.001) still remained significant.ConclusionsYoung PD patients with preserved LVEF already exhibited myocardial diastolic dysfunction. Global diastolic strain rate indexes were valuable parameters to evaluate diastolic dysfunction. Additionally, LVPWT was highly correlated with DSrE, such parameter should be taken into account for predicting the early LV diastolic dysfunction in clinical practice.

Peritoneal dialysis during congenital heart surgery admissions: insights from a large database.

The management of fluid overload after congenital heart surgery has been limited to diuretics, fluid restriction, and dialysis. This study was conducted to determine the association between peritoneal dialysis and important clinical outcomes in children undergoing congenital heart surgery. A retrospective review was conducted to identify patients under 18 years of age who underwent congenital heart surgery. The data were obtained over a 16-year period (1997-2012) from the Kids' Inpatient Database. Data analysed consisted of demographics, diagnoses, type of congenital heart surgery, length of stay, cost of hospitalisation, and mortality. Logistic regression was performed to determine factors associated with peritoneal dialysis. A total of 46,176 admissions after congenital heart surgery were included in the study. Of those, 181 (0.4%) utilised peritoneal dialysis. The mean age of the peritoneal dialysis group was 7.6 months compared to 39.6 months in those without peritoneal dialysis. The most common CHDs were atrial septal defect (37%), ventricular septal defect (32.6%), and hypoplastic left heart syndrome (18.8%). Univariate analyses demonstrated significantly greater length of stay, cost of admission, and mortality in those with peritoneal dialysis. Regression analyses demonstrated that peritoneal dialysis was independently associated with significant decrease in cost of admission (-$57,500) and significant increase in mortality (odds ratio 1.5). Peritoneal dialysis appears to be used in specific patient subsets and is independently associated with decreased cost of stay, although it is associated with increased mortality. Further studies are needed to describe risks and benefit of peritoneal dialysis in this population.

SUN-221 RATES OF HOSPITALISATION IN THE FIRST YEAR AFTER COMMENCEMENT OF RENAL REPLACEMENT THERAPY- SINGLE CENTRE EXPERIENCE

Renal replacement therapy (RRT) patients are known to have large number of comorbidities and hence, have high hospitalisation rates. The primary aim of the present study was to compare rates of hospitalisation in year one of incident dialysis patients treated with peritoneal dialysis (PD) or with haemodialysis (HD). We performed retrospective review of all the patients who commenced RRT during April 2013 to March 2016. We collected demographic data, date of commencement of RRT, starting modality, first contact date with renal services, type of access, Charlson’s comorbidity score (CCS) and the details regarding hospital admission within the first year of starting RRT including data about switching modality from electronic patient records. Data was analysed using SPSS V24. 200 patients commenced RRT over 3 year from April 2013-March 2016. Median age of starting RRT was 61.7 years (IQR: 21), 66% (n=132) were males and majority were whites (83.5%). Median CCS was 5 (IQR: 3) and 41.5% were diabetics. 107 patients commenced RRT on HD and rest of 93 on PD. During the one-year follow up period after starting RRT, there were 434 admissions in 130 (65%) patients. 70 (65.4%) of 107 HD and 60 (64.5%) of 93 PD patients were admitted atleast once during the first year of RRT. Median number of admissions were 2.5 (IQR: 3) and cumulative in-patient days in 1 year were 12 (IQR: 27). On comparison of patients groups by starting modality, HD patients were older (65 years; IQR 23 years) as compared to PD patients (58.7 years; IQR 16 years) (P=0.003). There were 236 admissions in HD group and 198 in PD group, however there were more admissions related to medical issues (32% in HD vs 19 % in PD) in HD group vs more admissions related to dialysis issues (9% in HD vs 13% in PD) in PD group. CCS was higher in HD at 6 (IQR 3) as compared to PD patients which was 5 (IQR 3) (P= 0.017). Median number of admission HD vs PD were 2 (IQR: 2) vs 3 (IQR: 3) (P = 0.801) and cumulative days of admission in HD vs PD were 13 (IQR: 27) vs 10.5 (IQR: 23) (P=0.504). Burden of hospitalisation is high in renal replacement therapy population. Even though there was significant difference in the age and comorbidity index of the patients in both admitted HD and PD groups, there was no difference in the number of admission and the hospital days between groups. Further work is required to explore factors contributing the above.

Atrial fibrillation and associated outcomes in patients with peritoneal dialysis and hemodialysis: a 14-year nationwide population-based study.

Patients with end-stage renal disease (ESRD) undergoing dialysis have increased risks of atrial fibrillation (AF). To investigate dialysis-related incident AF and associated outcomes. Patients with dialysis were retrieved using data from Taiwan National Health Insurance Research Database during 2001-2013. Patients were separated into peritoneal dialysis (PD) and hemodialysis (HD) according to their initial modality. Primary outcome was new-onset AF. Secondary outcomes were AF-associated ischemic stroke (IS)/systemic embolism (SE) and hemorrhagic stroke. A total of 158,910 dialytic patients were retrieved. After exclusion criteria, a total of 117,023 patients with ESRD undergoing dialysis were separated into 12,659 patients on PD and 104,364 patients on HD. There were 458 PD patients with subsequent development of AF, and 6216 HD patients with subsequent development of AF. At end of follow-up, patients on PD and HD had AF incidence densities of 7.8 and 8.8 events per 1000 person-years, the SHR of PD versus HD was 0.83 (95% CI 0.73-0.94). The SHR of PD versus HD was 1.07 (95% CI 0.80-1.44) for IS/SE and the SHR of PD versus HD was 0.34 (95% CI 0.13-0.90) for hemorrhagic stroke. In patients with ESRD undergoing dialysis, PD had lowered risks of new onset of AF compared to HD. Subsequently, these AF patients in PD group had comparable incidence of ischemic stroke but decreased incidence of hemorrhagic stroke compared to AF patients in HD group. PD could be the most suitable modality in patients at risk for the onset of AF.

The relationship between oral diseases and infectious complications in patients under dialysis.

Association was investigated between oral health before dialysis and the incidence of systemic infections during dialysis. We hypothesized that low-grade systemic inflammation caused by poor oral health associates with infectious episodes in patients on dialysis, despite earlier eradication of oral infection foci. A total of 117 patients (46 with peritoneal and 71 with hemodialysis) were examined and treated at predialysis stage and followed up during dialysis. Number of infection episodes and microorganisms cultured from blood and peritoneal fluid were analyzed. Number of teeth, periodontal inflammatory burden, and total dental index scores were assessed, and salivary matrix metalloproteinase 8, triggering receptor on myeloid cells 1, peptidoglycan recognition protein 1 (PGLYRP1), and interleukin-1β were measured. In hemodialysis, 134 infection episodes were recorded, while peritoneal dialysis group had 77 peritonitis episodes. Culture-negative samples were 69% in hemodialysis and 23% in peritoneal dialysis group. Staphylococci were the most frequently associated microorganisms. Infections during dialysis did neither associate with oral health parameters nor associate with salivary inflammatory biomarkers, except for PGLYRP1, which associated with number of infection episodes during hemodialysis (p=.046). A number of infection episodes during hemodialysis were associated with salivary PGLYRP1 but not the other salivary markers or oral infection markers.

Lifetime cost-effectiveness analysis of first-line dialysis modalities for patients with end-stage renal disease under peritoneal dialysis first policy

BackgroundThis study aimed to determine the lifetime cost-effectiveness of first-line dialysis modalities for end-stage renal disease (ESRD) patients under the “Peritoneal Dialysis First” policy.MethodsLifetime cost-effectiveness analyses from both healthcare provider and societal perspectives were performed using Markov modelling by simulating at age 60. Empirical data on costs and health utility scores collected from our studies were combined with published data on health state transitions and survival data to estimate the lifetime cost, quality-adjusted life-years (QALYs) and cost-effectiveness of three competing dialysis modalities: peritoneal dialysis (PD), hospital-based haemodialysis (HD) and nocturnal home HD.ResultsFor cost-effectiveness analysis over a lifetime horizon from the perspective of healthcare provider, hospital-based HD group (lifetime cost USD$142,389; 6.58 QALYs) was dominated by the PD group (USD$76,915; 7.13 QALYs). Home-based HD had the highest effectiveness (8.37 QALYs) but with higher cost (USD$97,917) than the PD group. The incremental cost-effectiveness ratio (ICER) was USD$16,934 per QALY gained for home-based HD over PD. From the societal perspective, the results were similar and the ICER was USD$1195 per QALY gained for home-based HD over PD. Both ICERs fell within the acceptable thresholds. Changes in model parameters via sensitivity analyses had a minimal impact on ICER values.ConclusionsThis study assessed the cost-effectiveness of dialysis modalities and service delivery models for ESRD patients under “Peritoneal Dialysis First” policy. For both healthcare provider and societal perspectives, PD as first-line dialysis modality was cost-saving relative to hospital-based HD, supporting the existing PD First or favoured policy. When compared with PD, Nocturnal home Home-based HD was considered a cost-effective first-line dialysis modality for ESRD patients.

Economic burden and cost-utility analysis of three renal replacement therapies in ESRD patients from Yunnan Province, China.

To compare the economic burden and cost-utility analysis of the renal replacement therapies, including hemodialysis (HD), peritoneal dialysis (PD), and allograft kidney transplantation (KT) among end-stage renal disease (ESRD) patients from Yunnan Province, China. Multistage stratified random sampling method was used to select presentative sample of 298 patients from four hospitals in Yunnan Province. The two-step model was applied to calculate a direct economic burden; the human capital approach was used to analyze the indirect economic burden. SF-36 scale was applied to assess the quality of life, while the improving score of quality of life was used to evaluate the cost-utility score. A total of 298 patients were analyzed, including 108 HD patients, 91 PD patients and 99 KT patients. The mean unit economic expenses of HD, PD, and KT were $11,783.6 ± 402.63, $11,059.8 ± 709.51, and $21,151.1 ± 11,419.57, respectively. Based on the cost-utility analysis, the cost of improving one unit of quality of life in KT, PD, and HD was $599.86, $1373.89 and $2021.20, respectively; a significant difference was observed between the KT group and the HD or PD group (P < 0.05). The economic burden of ESRD in Yunnan was substantial. The cost-utility was the best in the renal transplantation group. Kidney transplantation is still recommended as the first approach for patients with ESRD, followed by PD.

Uric acid levels and clearance in chronic kidney disease patients

Aim: Uric acid levels increase in chronic renal failure especially due to protein metabolism. In this study, we aimed to compare uric acid clearance who are also nephrotoxic in patients with end-stage renal disease. Methods: Sixty-one chronic peritoneal dialysis (PD) patients and fifty-one chronic hemodialysis (HD) patients included in the study. Duration of PD and HD, uric acid levels, age and gender of the patients evaluated. Uric acid levels in PD patients and HD patients compared. Results: The mean ages of PD and HD patients were 56.77 ±13.58 and 57.25 ± 16.45 years, respectively (p=0.864). The number of male patients was more in the PD group and female in the HD group (p=0.959). The duration of dialysis was 3.25 in PD, 3.75 in HD (p=0.925). The mean uric acid levels were 5.54 ± 1.13 mg/dL in PD patients, and 5.76 ±1.52 mg/dL in HD patients (p=0.389). Conclusion: Dialysis is used to remove toxins in end-stage renal disease. Uric acid levels may be elevated in patients with end-stage renal disease. There is no difference in uric acid clearance in PD and HD patients.