Transcript What is the Role of in Optimising ESRD Patient Outcomes? Peritoneal Dialysis

What is the Role of
Peritoneal Dialysis
in Optimising ESRD
Patient Outcomes?
Goals Before and Following
Initiation of Dialysis
Initiation of Dialysis
Pre-ESRD
Slow Progression of Renal Disease
Prevent Additional Injury to Kidneys
Manage Co-morbid Conditions
– Cardiovascular Disease
– Diabetes
– Anemia
Preserve Vascular Access Site
Maintain Proper Nutrition
Pre-dialysis Education for Patient
PD: Optimising Outcomes?
ESRD
Preserve Residual Renal Function
Prevent Additional Injury to Kidneys
Delay Long Term Complications
Manage Co-morbid Conditions
– Cardiovascular Disease
– Diabetes
– Anemia
Preserve/Maintain Vascular Access Site
Maintain Proper Nutrition
Patient Social and Employment
Rehabilitation
Blood Purification
Electrolyte and Acid Base Equilibrium
Non-Medical Factors that Impact
on ESRD Modality Selection
Nissenson AR, Kidney Int, 1993; 43 (Suppl. 40):S120-S127
• Financial/reimbursement
• Physician experience with both therapies
• Patient and family understanding of modality
options
• Availability of resources (staff, finance, space, etc)
• Social factors
• Cultural habits
PD: Optimising Outcomes?
Modality Selection and Distribution
Where Do We Want To Be?
PD: Optimising Outcomes?
Total survival is more important than
survival on each therapy
Van Biesen 2000
“What patients want to know is which sequence of RR
modalities will increase their survival as long as
possible & this with the best Quality of Life”
HD
TX
PD
PD: Optimising Outcomes?
Integrated Care Approach
Lameire N, et al, Seminar of Uro-Nephrology, (1999)
“Start renal replacement therapy in ESRD
patients with PD, transfer them to HD when
problems with PD occur, and transplant
them when the possibility exists”
PD: Optimising Outcomes?
Integrated care concept:
• Patient survival and quality of life are two very important
factors in the selection of a dialysis modality
• The majority of studies have compared the two modalities
as « competitors » rather than as « complementary »
techniques
• Since every RRT has a technical « drop-out », it is very
likely that a patient will need several modalities during his
lifetime and transfer from one technique to another will
often be needed.
PD: Optimising Outcomes?
Integrated Therapy - questions
• Does the physician believe that all RRT modalities
should be made available to each patient ?
• Should the patient have a free choice?
• Does each RRT modality have a role to play during the
lifetime of a patient with renal failure ?
PD: Optimising Outcomes?
Reasons for Modality Switch
Van Biesen WE, et al, J Am Soc Nephrol 2000;11:116-125
50
50%
40%
Percent of patients
40
30
25%
25%
23%
20
12%
14%
11%
10
0
Access
Problems
CV Poor BP Personal
Problems Control Choice
Haemodialysis to Peritoneal Dialysis
PD: Optimising Outcomes?
Peritonitis Social Adequacy Leakage of
Exit-Site Problems or UF Dialysis Fluid
Peritoneal Dialyisis to Haemodialysis
Integrated ESRD Care
Creatinine Clearance (ml/min)
Residual Renal
Function
20
15
Transplant
Peritoneal Dialysis
PD
10
Hemodialysis
5
0
Time on Dialysis
Initiation of Dialysis
PD: Optimising Outcomes?
Challenges for PD
• Can PD stand on an equal footing with HD?
• If PD is to be used for RRT, it must give equivalent
results both for mortality and morbidity as does HD
PD: Optimising Outcomes?
Where is PD today?
• Similar survival to HD
• PD is treatment of choice for children
• Peritonitis and exit-site infection rates have been
reduced
• Clearance targets can be achieved
• Lower costs than HD
• Good treatment prior to transplantation
PD: Optimising Outcomes?
PD as the Initial Form of Renal
Replacement Therapy
•
•
•
•
•
•
•
Better initial survival
Preserves residual renal function
Effective blood pressure and volume control
PD  Transplant: reduced risk of early acute renal failure
Reduced risk of being infected by a blood borne virus
Delays the use of HD blood access sites
Quality of life
PD: Optimising Outcomes?
Initial Survival Advantage of PD Canadian Results
Fenton AJKD 30:334-42, 1997
100
P<0.001
Patient Survival (%)
90
80
70
PD
HD
60
50
40
30
0
6
12
18
24
30
Months
PD: Optimising Outcomes?
36
42
48
54
10663 patients
Comparing Survival of “Integrated Care”
Patients with HD Patients
Van Biesen JASN 2000; 11:116-25
1
0 .9
0 .8
Survival
0 .7
0 .6
0 .5
PD to HD
0 .4
0 .3
p=0 .0 1 (lo g-ra nk)
0 .2
HD
0 .1
0
0
50
100
M o nths
PD: Optimising Outcomes?
150
Possible Causes
• Better preservation of residual renal function in PD.
Moist JASN 11:556-64, 2000
• The ”unphysiology” of HD.
Kjellstrand KI 7(S2):530-36, 1975
Lopot NDT 13(S6):74-78, 1998
• Monday HD mortality increased 58% relative to other days.
Bleyer KI 55:1553-9, 1999
PD: Optimising Outcomes?
PD as the Initial Form of Renal
Replacement Therapy
•
•
•
•
•
•
•
Better initial survival
Preserves residual renal function
Effective blood pressure and volume control
PD  Transplant: reduced risk of early acute renal failure
Reduced risk of being infected by a blood borne virus
Delays the use of HD blood access sites
Quality of life
PD: Optimising Outcomes?
Preservation of residual renal function
Residual Creatinine Clearance
(ml/min)
Lysaght et al, ASAIO Trans, 1991; 37:598-604
5
CAPD (n=58)
HD (n=57)
4
3
2
1
0
0
6
12
18
24
30
Time on therapy in months
PD: Optimising Outcomes?
36
42
48
Preservation of residual renal function
Lang et al, PDI 21:52-57, 2001
RRF (ml/min/1.73 m2)
8
7
CAPD
HD-LF
HD-HF
6
5
4
3
2
1
0
0
6
12
18
Months
PD: Optimising Outcomes?
24
30
* p<0.05
** p<0.01
*** p<0.001
Risk of RRF Loss
Moist JASN 11:556-565, 2000
**
***
Calcium Channel Blocker
ACE Inhibitor
***
Hemodialysis
*
Serum Calcium (mg/dl)
Congestive Heart Failure
*
Diabetes
***
***
Non-white Race
Female Sex
Time to Followup (yrs)
0
1843 patients
PD: Optimising Outcomes?
0.5
1
1.5
**
*
2
2.5
Odds Ratio Multivariate Analysis
3
What are the benefits of preserving
residual renal function?
Davies, S., 2000
Provides endocrine functions
• Erythropoietin production
• Ca++, phosphorus and vitamin D homeostasis
Contributes to total solute clearance
(1 ml/min CrCl = 10 liter CrCl/week)
Improves
2-microglobulin and
middle molecule
clearance
Reduces
Mortality
Improves QoL
Facilitates volume
control
Increases total
Na removal
Improves nutritional
status
PD: Optimising Outcomes?
Allows for more
liberal diet and fluid
intake
Causes of RRF Preservation in PD
• Avoidance of Dehydration
• HD: production of inflammatory mediators by blood contact
McCarthy JASN 4:367, 1993
Lysaght ASAIO Trans 37:598-604, 1991
• Better clearance of middle molecules, lipophilic and
proteinbound toxins.
PD: Optimising Outcomes?
Serum CRP Values
Haubitz et al. PDI 16(2): 158-162, 1996
Serum CRP, ng/ml
6000
*#
5000
*p<0.01 vs. control
#p<0.01 vs. PD
4000
3000
*
*
2000
1000
0
n=33
Healthy
Control
PD: Optimising Outcomes?
n=21
HD
n=24
PD
n=16
CRF
Without dialysis
PD as the Initial Form of Renal
Replacement Therapy
•
Better initial survival
•
Preserves residual renal function
•
Effective blood pressure and volume control
•
PD
•
Reduced risk of being infected by a blood borne virus
•
Delays the use of HD blood access sites
•
Quality of life
Transplant: reduced risk of early acute renal failure
PD: Optimising Outcomes?
Difference in BP Control by Dialysis
Modality
Mailloux AJKD 1998; 32(S3), S120-S141
• The prevalence of hypertension in HD patients is approximately
80% vs. approximately 50% in PD patients.
• “Hypertension is not optimally controlled in HD and PD, but is
better controlled in PD than HD”
• “Lower blood pressure in PD patients is attributed to the more
successful achievement of dry weight by slower ultrafiltration”
NKF Taskforce on CV Disease
PD: Optimising Outcomes?
Effect of CAPD Blood Pressure Control
Saldanha AJKD 1993; 21:184-188
20
Patients transferred from HD to PD (n = 67)
% Variation From Baseline
15
10
Hematocrit
Weight
Blood Pressure
5
0
-5
* *
* *
*
*
* p<0.05
-10
*
*
*
8
9
* *
*
-15
0
1
2
3
4
PD: Optimising Outcomes?
5
6
7
Months
10
11
12
Modality and Cardiovascular Disease
Percent of patients
Canziani MD, et al, Artificial Organs, 1995; 19:241-244
100
90
80
70
60
50
40
30
20
10
0
81%
HD (n=27)
CAPD (n=27)
74%
41%
33%
25%
4%
Hypertension
PD: Optimising Outcomes?
Arrhythmias
Severe
Arrhytmias
PD as the Initial Form of Renal
Replacement Therapy
•
Better initial survival
•
Preserves residual renal function
•
Effective blood pressure and volume control
•
PD
•
Reduced risk of being infected by a blood borne virus
•
Delays the use of HD blood access sites
•
Quality of life
Transplant: reduced risk of early acute renal failure
PD: Optimising Outcomes?
Transplantation and the role of PD
* Perez Fontan M, Perit Dial Int, 1996, 16: 48-54
• Graft function immediately after transplantation is important
• 24% of PD patients have delayed graft function (DGF) vs. 50% of
HD patients*
• Patients with delayed graft function have a 10% decreased graft
survival
• Reduced need of post-transplantation dialysis
• PD patients have lower usage of immunosuppressive medication*
• PD patients suffer a lower incidence of late infections*
PD: Optimising Outcomes?
Dialysis Modality and Delayed Graft
Function
Bleyer et al. J Am Soc Nephrol 10:154-159, 1999
Group
PD
HD
P Value
% anuric in first 24 h
8.3
11.9
<0.001
% dialysis in first week
20.0
28.6
<0.001
% treated for rejection
12.0
12.9
0.20
% non-functioning graft at
discharge
13.7
14.8
0.14
PD: Optimising Outcomes?
PD as the Initial Form of Renal
Replacement Therapy
•
Better initial survival
•
Preserves residual renal function
•
Effective blood pressure and volume control
•
PD
•
Reduced risk of being infected by a blood borne virus
•
Delays the use of HD blood access sites
•
Quality of life
•
Cheaper
Transplant: reduced risk of early acute renal failure
PD: Optimising Outcomes?
Hepatitis B & C
Cendoroglo Neto NDT 10:240-46, 1995
Seroconversion (%/yr)
P<0.001
20
18
16
14
12
10
8
6
4
2
0
P<0.02
HD
PD
Hepatitis B Hepatitis C
PD: Optimising Outcomes?
• 309 patients
• Brazil
• High background
prevalence of Hepatitis B
&C
• Seroconversion partly
related to blood
transfusion (p=0.05)
Modality and Hepatitis C
Pereira B. Kidney Int, 1997; 51:981-999
60%
50%
44%
PD
40%
31%
30%
20%
19%
16%
8%
ty
re
2%
cI
n
D
us
so
l
B
ar
ril
as
Se
lg
H
ua
ng
sh
id
a
Yo
PD: Optimising Outcomes?
2%
an
o
0%
0%
7%
5%
B
ru
gn
5%
C
ha
n
10%
13%
12%
M
15%
as
20%
25%
Jo
n
Percent of patients
HD
47%
50%
Why lower risk of HCV in PD?
Pereira KI 1997; 51:981-999
• Lower requirement for blood transfusion than HD
patients
• The absence of a vascular access site and
extracorporeal blood circuit reduces the risk for
parenteral exposure to the virus
• PD is a home therapy and it offers a more isolated
environment
PD: Optimising Outcomes?
PD as the Initial Form of Renal
Replacement Therapy
•
Better initial survival
•
Preserves residual renal function
•
Effective blood pressure and volume control
•
PD
•
Reduced risk of being infected by a blood borne virus
•
Delays the use of HD blood access sites
•
Quality of life
Transplant: reduced risk of early acute renal failure
PD: Optimising Outcomes?
Total lifespan of vascular access
• Creation and maintenance of adequate vascular
access remains a major problem in HD
• ESRD patients have compromised cardiovascular
systems
• Any strategy that can augment the total lifespan of
vascular access is of value
• Additional time is “won” by starting PD
PD: Optimising Outcomes?
Modality and EPO - Japan
Shinzato T, et al, Kidney Int, 1999; 5:700-712
Percent of patients
50
Hemodialysis
Peritoneal Dialysis
40
30
20
10
0
Not
used
1 - 1499
1500 2999
3000 4499
4500 5999
rHuEPO dose (units/week)
PD: Optimising Outcomes?
6000 8999
9000 +
Modality and EPO - Europe
rHuEpo dose (units/week)
House AA, et al, Nephrol Dial Transplant, 1998; 13:1763-1769
8,000
6,000
7,370 Units
5,790 Units
4,000
2,000
0
Hemodialysis (n=157)
PD: Optimising Outcomes?
Peritoneal Dialysis (n=126)
Modality and Transfusions
House AA, et al, Nephrol Dial Transplant, 1998; 13:1763-1769
Parameter
P
PD
HD
(n=157) (n=126) value
Hemoglobin (g/dl)
10.47
10.71
0.45
Serum ferritin (g/dl)
258.7
253.8
0.77
Transferrin saturation (%)
28.5
28.1
0.94
Mean number of transfusions
4.59
2.17
0.01
52.9%
40.9%
0.01
% of patients receiving transfusion
PD: Optimising Outcomes?
What is the Role of PD in Optimising
ESRD Patient Outcomes?
• Influenced by:
–
–
–
–
–
Availability of modality options
Profile of co-morbidities
Patient choice and self-care motivation
Physician experience and knowledge
Outcome evidence
PD: Optimising Outcomes?
Conclusion
Dratwa 1999
Following an integrated strategy of dialysis
that uses PD as an initial therapy then HD
may improve total patient survival and
preserve societal resources which could be
reallocated to treat more of the continuously
increasing population of ESRD patients.
PD: Optimising Outcomes?