Uptake Of Peritoneal Dialysis Research Articles

#6448 IMPACT OF PRE-DIALYSIS FOLLOW-UP ON OUTCOMES IN DIALYSIS PATIENTS

Abstract Background and Aims Pre-dialysis care aims to slow down the decline in kidney function and to prepare patients for their potential start of renal replacement therapy. Patients who received attention earlier showed reduced mortality and hospitalization, better uptake of peritoneal dialysis, and earlier placement of arteriovenous fistula for hemodialysis. The objective of this study is to analyze the impact of pre-dialysis care in dialysis patients from Fresenius Medical Care Latin America (FME LatAm). Method Patients incident to dialysis that started treatment at FME LatAm between January 2019 and December 2022 were included in this retrospective observational study. They were classified according to whether they received pre-dialysis care or not as CKD (more than 10 days of follow up;) or No CKD (less than 10 days). CKD group was subclassified regarding the length of stay in pre-dialysis care in 10 to 45 days (10-45), 45 to 90 days (45–90), and more than 90 days (>90). Demographic variables, vascular access, and lab variables were compared between CKD and No CKD, and within subgroups during the observation period. Values are expressed in mean ± SD. Values compared using Student t-test or ANOVA accordingly. Results CKD patients were older than No CKD (CKD: 61.5 ± 16.6 vs NoCKD: 60.6 ± 17.2; p = 0.02), with lower male prevalence (CKD: 57.5% vs NoCKD: 60.2%; p=0.001). No significative differences in prevalence of diabetes were found. Patients under pre-dialysis treatment showed a higher rate of PD referrals (CKD: 44.6% vs NoCKD: 7.3%; p <0.0001). Regarding vascular access, a higher percentage of CKD patients started dialysis with definitive access (AVF or AVG) (CKD: 47.9% vs NoCKD: 31.5%; p <0.0001). In the same way, prevalence of definitive accesses was higher in patients with longer CKD stay (10-45: 38.4%, 45-90: 57.3%, >90: 50.2%; p<0.0001). Within patients who started treatment with a catheter, a higher percentage of CKD patients already had a fistula or graft performed at treatment start (CKD: 7.3% vs NoCKD: 2.7%; p <0.0001). EPO prescription was higher as the time of follow-up was longer (10-45: 3.3%, 45-90: 7%, >90: 14.9%; p<0.0001). As expected for CKD patients haemoglobin was higher and ferritin was lower (Table 1). Though TSAT, Calcium, and Albumin were significative different between CKD and No CKD, the difference was not clinically relevant. Phosphorus and iPTH was higher in CKD patients and creatitine clearence calculated by MDRD was lower in those patients, opposite of expected (Table 1). Conclusion Older and male patients are more likely to have CKD follow-up. Pre-dialysis treatment has a deep impact on PD referral, EPO prescription, type of vascular access at admission, and ready-made vascular access at treatment start. Some laboratory results were not as expected, maybe due to non proper medication accessibility or inadequate financial support at predialysis stages. Even though, CKD follow-up is crucial to prepare patients for a better start of renal replacement therapy.

Effect of social deprivation on peritoneal dialysis uptake. A mediation analysis with the data of the REIN Registry

Social deprivation could act as a barrier to peritoneal dialysis. The objective of this study was to assess the association between social deprivation estimated by the European deprivation index (EDI) and peritoneal dialysis (PD) uptake and to explore the potential mediators of this association. From the REIN registry, patients who started dialysis in 2017 were included. The EDI was calculated based on the patient address. The event of interest was the proportion of PD 3 months after dialysis initiation. A mediation analysis with a counterfactual approach was carried out to evaluate the direct and indirect effect of the EDI on the proportion of PD. Emergency start and hemoglobin levels were tested as mediator. Among the 9588 patients included, 1116 patients were on PD; 2894 (30.2%) patients belonged to the most deprived quintile (Q5). PD was associated with age > 70 years (OR: 0.79 [95% CI: 0.69–0.91]), male gender (0.85 [95% CI: 0.74–0.97]), cardiovascular disease (OR: 0.86 [95% CI: 0.86–1.00]), chronic heart failure (OR: 1.34 [95% CI: 1.13–1.58]), active cancer (OR: 0.67 95% CI: [0.53–0.85]) and obesity (OR: 0.75 [95% CI: 0.63–0.89]). In the mediation analysis, Q5 had a direct effect on PD proportion OR: 0.84 [95% CI: 0.73–0.96]. The effect of Q5 on the proportion of PD was mediated by haemoglobin level at dialysis initiation (OR: 0.96 [95% CI: 0.94–0.98]) and emergency start (OR: 0.98 [95% CI: 0.96–0.99]). Social deprivation, estimated by the EDI, was associated with a lower PD uptake. The effect of social deprivation was mediated by haemoglobin level, a proxy of predialysis care and emergency start.

Early Referral to Nephrological Care and the Uptake of Peritoneal Dialysis. An Analysis of German Claims Data.

Background: Hemodialysis (HD) and peritoneal dialysis (PD) are medically equivalent alternatives for symptomatic therapy of end-stage renal disease (ESRD). An early referral (ER) of patients with chronic kidney disease (CKD) to a nephrological specialist is associated with a higher proportion of patients choosing PD. Germany historically shows a low PD uptake. This article is the first investigation into the impact of ER on the uptake of PD, using a large German claims database. Methods: Claims data of 4727 incident dialysis patients in 2015 and 2016 were analyzed. Accounting codes for nephrological care and dialysis modalities were identified. Their first documentation was defined as their first encounter with a nephrologist and their first dialysis treatment (HD or PD). ER was determined as receiving nephrological care at least six months before the first dialysis. A multivariate logistic regression model with adjusted odds ratios (AOR) investigates the impact of ER, outpatient dialysis start, age, comorbidities, and sex on the chance for PD. Results: Forty-three percent were referred to the nephrologist six months before their first dialysis (ER). Single tests, as well as the adjusted multivariate logistic regression, highlighted that ER significantly increases the chance for PD. In the multivariate model, the uptake of PD was associated with ER (AOR = 3.05; p < 0.001; 95% CI = 2.16–4.32), outpatient dialysis start (AOR = 0.71; p = 0.044; 95% CI = 0.51–0.99), younger age (AOR = 0.96; p < 0.001; 95% CI = 0.95–0.97), and fewer comorbidities (AOR = 0.85; p < 0.001; 95% CI = 0.44–1.58). Conclusions: ER of patients with CKD to a nephrologist increases PD uptake. It gives both nephrologists and patients enough time for patient education about different treatment options and can contribute to informed decisions about the dialysis treatment.

Effect of social deprivation on peritoneal dialysis uptake: A mediation analysis with the data of the REIN registry.

Social deprivation could act as a barrier to peritoneal dialysis (PD). The objective of this study was to assess the association between social deprivation estimated by the European deprivation index (EDI) and PD uptake and to explore the potential mediators of this association. From the Renal Epidemiology and Information Network registry, patients who started dialysis in 2017 were included. The EDI was calculated based on the patient's address. The event of interest was the proportion of PD 3 months after dialysis initiation. A mediation analysis with a counterfactual approach was carried out to evaluate the direct and indirect effect of the EDI on the proportion of PD. Among the 9588 patients included, 1116 patients were on PD; 2894 (30.2%) patients belonged to the most deprived quintile (Q5). PD was associated with age >70 years (odds ratio (OR) 0.79 [95% confidence interval (CI): 0.69-0.91]), male gender (0.85 [95% CI: 0.74-0.97]), cardiovascular disease (OR 0.86 [95% CI: 0.86-1.00]), chronic heart failure (OR 1.34 [95% CI: 1.13-1.58]), active cancer (OR 0.67 [95% CI: 0.53-0.85]) and obesity (OR 0.75 [95% CI: 0.63-0.89]). In the mediation analysis, Q5 had a direct effect on PD proportion OR 0.84 [95% CI: 0.73-0.96]. The effect of Q5 on the proportion of PD was mediated by haemoglobin level at dialysis initiation (OR 0.96 [95% CI: 0.94-0.98]) and emergency start (OR 0.98 [95% CI: 0.96-0.99]). Social deprivation, estimated by the EDI, was associated with a lower PD uptake. The effect of social deprivation was mediated by haemoglobin level, a proxy of predialysis care and emergency start.

SO005BARRIERS TO PERITONEAL DIALYSIS IN SASKATCHEWAN CANADA: RESULTS FROM A PROVINCE WIDE SURVEY

Abstract Background and Aims Peritoneal dialysis (PD) offers similar clinical outcomes to hemodialysis (HD) at a fraction of the cost. PD remains underutilized as remote HD patients in the province of Saskatchewan often relocate or travel hundreds of kilometers weekly in order to receive dialysis related care. Many barriers to patient uptake of PD have been described, but the scale of their impact on our patient population have not been quantified. To improve uptake of peritoneal dialysis in Saskatchewan, we need to address the most prominent barriers to patient access to PD to ensure that they truly have a choice in determining the modality with which they choose to dialyze. The purpose of this study was to determine the barriers to receiving PD in Saskatchewan Method We conducted a cross sectional survey of in-center HD patients across the province of Saskatchewan, Canada. A total of 740 in-center HD patients at two academic sites and 7 satellite units were approached by study coordinators. 421 patients (n=268 in the main units and n=153 in the satellite units) agreed to participate in the study. A questionnaire using a five-point Likert scale was created to identify barriers to PD with questions addressing PD awareness and knowledge, accessibility, and risks, fears, beliefs surrounding PD. Responses were anonymous and tabulated using a data collection tool. Survey data were summarized using descriptive statistics. Results 45.9% of participants had more than 12 years of formal education. 11% lived on farm, 19% on reserve, and 71% in town/city. The median (interquartile range=IQR) distance of home to in-center dialysis units was 10 (5-70) kilometers. Only 82% of patients were aware of PD as a treatment option. 35% of patients felt they had no understanding of the benefits or risks of PD. Despite only 13% of patients being told they were unsuitable for PD by their nephrologist, approximately half (47%) had ever considered it as a treatment option. Prominent barriers to PD that we identified were: excellent care in the HD unit (62%), proximity to dialysis unit (41%), unwilling to dialyze daily (36%), and unwilling to learn a new technique (34%). Beliefs held by patients that figured prominently in their decision to choose HD over PD included not wanting to take their disease home (32%), fear of being a burden on family (32%), lack of space (28%), risk of infection, issues with self-image while on PD, and PD being an inferior modality to HD (all approximately 24%). Conclusion Several barriers to PD were identified with a few consistent themes being identified, including deficiencies in knowledge, patient specific beliefs, poor patient education, and perceived benefits of in-center care (satisfaction with current care). The most frequently reported knowledge barrier was a lack of understanding of benefits and risks of PD. These findings suggest that not enough patients are receiving formal education, or active involvement in deciding which modality they would be most suitable for them when initiating dialysis. To improve uptake of PD in Saskatchewan, we will have to generate both increased awareness of PD as a treatment modality, alongside improved educational strategies to enable patients to make an informed choice about how they receive renal replacement therapy. While the study does not reflect the views of all patients, the information gained will be valuable in designing an educational program to improve adoption of PD within our province.

Increasing uptake of peritoneal dialysis in ESRD cost saving in UK

Increasing uptake of peritoneal dialysis in ESRD cost saving in UK

Early referral to specialist nephrology services for preventing the progression to end-stage kidney disease.

Early referral of patients with chronic kidney disease (CKD) is believed to help with interventions to address risk factors to slow down the rate of progression of kidney failure to end-stage kidney disease (ESKD) and the need for dialysis, hospitalisation and mortality. We sought to evaluate the benefits (reduced hospitalisation and mortality; increased quality of life) and harms (increased hospitalisations and mortality, decreased quality of life) of early versus late referral to specialist nephrology services in CKD patients who are progressing to ESKD and RRT. In this review, referral is defined as the time period between first nephrology evaluation and initiation of dialysis; early referral is more than one to six months, whereas late referral is less than one to six months prior to starting dialysis. All-cause mortality and hospitalisation and quality of life were measured by the visual analogue scale and SF-36. SF-36 and KDQoL are validated measurement instruments for kidney diseases. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2012; Issue 1) which contains the Cochrane Renal Group's Specialised Register; MEDLINE (1966 to February 2012), EMBASE (1980 to February 2012). Search terms were approved by the Trial Search Co-ordinator. Randomised controlled trials (RCTs), quasi-RCTs, prospective and retrospective longitudinal cohort studies were eligible for inclusion. Two authors independently assessed study quality and extracted data. Events relating to adverse effects were collected from the studies. No RCTs or quasi-RCTs were identified. There were 40 longitudinal cohort studies providing data on 63,887 participants; 43,209 (68%) who were referred early and 20,678 (32%) referred late.Comparative mortality was higher in patients referred to specialist services late versus those referred early. Risk ratios (RR) for mortality reductions in patients referred early were evident at three months (RR 0.61, 95% CI 0.55 to 0.67; I² = 84%) and remained at five years (RR 0.66, 95% CI 0.60 to 0.71; I² = 87%). Initial hospitalisation was 9.12 days shorter with early referral (95% CI -10.92 to -7.32 days; I² = 82%) compared to late referral. Pooled analysis showed patients referred early were more likely than late referrals to initiate RRT with peritoneal dialysis (RR 1.74, 95% CI 1.64 to 1.84; I² = 92%).Patients referred early were less likely to receive temporary vascular access (RR 0.47, 95% CL 0.45 to 0.50; I² = 97%) than those referred late. Patients referred early were more likely to receive permanent vascular access (RR 3.22, 95% CI 2.92 to 3.55; I² = 97%). Systolic blood pressure (BP) was significantly lower in early versus late referrals (MD -3.09 mm Hg, 95% CI -5.23 to -0.95; I² = 85%); diastolic BP was significantly lower in early versus late referrals (MD -1.64 mm Hg, 95% CI -2.77 to -0.51; I² = 82%). EPO use was significantly higher in those referred early (RR 2.92, 95% CI 2.42 to 3.52; I² = 0%). eGFR was higher in early referrals (MD 0.42 mL/min/1.73 m², 95% CI 0.28 to 0.56; I² = 95%). Diabetes prevalence was similar in patients referred early and late (RR 1.05, 95% CI 0.96 to 1.15; I² = 87%) as was ischaemic heart disease (RR 1.05, 95% CI 0.97 to 1.13; I² = 74%), peripheral vascular disease (RR 0.99, 95% CI 0.84 to 1.17; I² = 90%), and congestive heart failure (RR 1.00, 95% CI 0.86 to 1.15; I² = 92%). Inability to walk was less prevalent in early referrals (RR 0.66, 95% CI 0.51 to 0.86). Prevalence of chronic obstructive pulmonary disease was similar in those referred early and late (RR 0.89, 95% CI 0.70 to 1.14; I² = 94%) as was cerebrovascular disease (RR 0.90, 95% CI 0.74 to 1.11; I² = 83%).The quality of the included studies was assessed as being low to moderate based on the Newcastle-Ottawa Scale. Slight differences in the definition of early versus late referral infer some risk of bias. Generally, heterogeneity in most of the analyses was high. Our analysis showed reduced mortality and mortality and hospitalisation, better uptake of peritoneal dialysis and earlier placement of arteriovenous fistulae for patients with chronic kidney disease who were referred early to a nephrologist. Differences in mortality and hospitalisation data between the two groups were not explained by differences in prevalence of comorbid disease or serum phosphate. However, early referral was associated with better preparation and placement of dialysis access.

Choosing dialysis modality: decision making in a chronic illness context.

Patients with chronic kidney disease (CKD) are encouraged to make an informed decision about dialysis. Survival rates for dialysis are equivalent yet there is wide variation in peritoneal dialysis uptake in the adult UK population. It is unclear how much is attributable to variations in patients' preferences. Kidney function usually declines over months and years; few studies have addressed how a chronic illness context affects choice. This study describes patients' decision making about dialysis and understands how the experience of CKD is associated with treatment choice. Survey employing interview methods explored 20 patients' views and experiences of making their dialysis choice. Data were analysed using thematic framework analysis to provide descriptive accounts of how patients experienced their illness and made treatment decisions. Patients talked about challenges of living with CKD. Patients were provided with lots of information about treatment options in different formats. Patients did not distinguish between different types of dialysis and/or have an in-depth knowledge about options. Patients did not talk about dialysis options as a choice but rather as a treatment they were going to have. Most patients perceived their choice as between 'dialysis' and 'no dialysis'. They did not perceive themselves to be making an active choice. Possibly, patients feel they do not need to engage with the decision until symptomatic. Despite lots of patient information, there were more opportunities to encounter positive information about haemodialysis. A more proactive approach is required to enable patients to engage fully with the dialysis treatment options.

Outcomes of Early versus Late Nephrology Referral in Chronic Kidney Disease: A Systematic Review

Background As late provision of specialist care, before starting dialysis therapy, is believed to be associated with increased morbidity and mortality, a systematic review was undertaken to evaluate clinical outcomes relating to early versus late referral of patients to nephrology services. Methods Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and EMBASE were searched up until September 2008 for studies of early versus late nephrology referral in adult (>18 years) patients with chronic kidney disease. Early referral was defined by the time period at which patients were referred to a nephrologist. Findings No randomized controlled trials were found. Twenty-seven longitudinal cohort studies were included in the final review, providing data on 17,646 participants; 11,734 were referred early and 5912 (33%) referred late. Comparative mortality was higher in patients referred to a specialist late versus those referred early. Odds ratios (OR) for mortality reductions in patients referred early were evident at 3 months (OR 0.51; 95% confidence interval [CI], 0.44-0.59) and remained at 5 years (OR 0.45; 95% CI, 0.38-0.53), both P <.00001. Initial hospitalization was 8.8 days shorter with early referral (95% CI, −10.7 to −7.0 days; P <.00001). Differences in mortality and hospitalization data between the 2 groups were not explained by differences in prevalence of diabetes mellitus, previous coronary artery disease, blood pressure control, serum phosphate, and serum albumin. However, early referral was associated with better preparation and placement of dialysis access. Conclusion Our analyses show reduced mortality and hospitalization, better uptake of peritoneal dialysis, and earlier placement of arteriovenous fistula for hemodialysis with early nephrology referral.