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

What is the Role of Peritoneal Dialysis in Optimising ESRD Patient Outcomes?. Initiation of Dialysis. Goals Before and Following Initiation of Dialysis. Pre-ESRD. ESRD. Slow Progression of Renal Disease Prevent Additional Injury to Kidneys Manage Co-morbid Conditions

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

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  1. What is the Role of Peritoneal Dialysisin Optimising ESRD Patient Outcomes?

  2. Initiation of Dialysis Goals Before and Following Initiation of Dialysis Pre-ESRD 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 • 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

  3. 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

  4. Modality Selection and DistributionWhere Do We Want To Be?

  5. 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

  6. Integrated Care Approach Lameire N, et al, Seminar of Uro-Nephrology, (1999) “Start renal replacement therapy in ESRDpatients with PD, transfer them to HD when problems with PD occur, and transplant them when the possibility exists”

  7. 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.

  8. 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 ?

  9. Reasons for Modality Switch Van Biesen WE, et al, J Am Soc Nephrol 2000;11:116-125 50 50% 40% 40 30 25% 25% 23% Percent of patients 20 14% 12% 11% 10 0 Access CV Poor BP Personal Peritonitis Social Adequacy Leakage of Problems Problems Control Choice Exit-Site Problems or UF Dialysis Fluid Haemodialysis to Peritoneal Dialysis Peritoneal Dialyisis to Haemodialysis

  10. Integrated ESRD Care Residual Renal Function 20 15 10 5 0 Transplant Peritoneal Dialysis PD Creatinine Clearance (ml/min) Hemodialysis Time on Dialysis Initiation of Dialysis

  11. 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

  12. 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

  13. 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

  14. Initial Survival Advantage of PD - Canadian Results Fenton AJKD 30:334-42, 1997 P<0.001 Patient Survival (%) 10663 patients Months

  15. Comparing Survival of “Integrated Care” Patients with HD Patients Van Biesen JASN 2000; 11:116-25 PD to HD HD

  16. 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

  17. 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

  18. 5 CAPD (n=58) 4 HD (n=57) 3 Residual Creatinine Clearance (ml/min) 2 1 0 0 6 12 18 24 30 36 42 48 Time on therapy in months Preservation of residual renal function Lysaght et al, ASAIO Trans, 1991; 37:598-604

  19. Preservation of residual renal function Lang et al, PDI 21:52-57, 2001

  20. * p<0.05 ** p<0.01 *** p<0.001 Risk of RRF Loss Moist JASN 11:556-565, 2000 ** *** *** * * ** *** *** * 1843 patients Odds Ratio Multivariate Analysis

  21. 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 Allows for more liberal diet and fluid intake Improves nutritional status

  22. 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.

  23. Serum CRP Values Haubitz et al. PDI 16(2): 158-162, 1996 6000 * # *p<0.01 vs. control #p<0.01 vs. PD 5000 n=21 4000 Serum CRP, ng/ml 3000 * * 2000 n=16 n=24 1000 n=33 0 Healthy Control HD CRF Withoutdialysis PD

  24. 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

  25. 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

  26. Hematocrit Effect of CAPD Blood Pressure Control Saldanha AJKD 1993; 21:184-188 20 Patients transferred from HD to PD (n = 67) 15 10 5 % Variation From Baseline Weight 0 Blood Pressure -5 * * * * * * * * * * * -10 * p<0.05 * -15 0 1 2 3 4 5 6 7 8 9 10 11 12 Months

  27. Modality and Cardiovascular Disease Canziani MD, et al, Artificial Organs, 1995; 19:241-244

  28. 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

  29. 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*

  30. 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 Dialysis Modality and Delayed Graft Function Bleyer et al. J Am Soc Nephrol 10:154-159, 1999

  31. 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 • Cheaper

  32. Hepatitis B & C Cendoroglo Neto NDT 10:240-46, 1995 P<0.001 P<0.02 • 309 patients • Brazil • High background prevalence of Hepatitis B & C • Seroconversion partly related to blood transfusion (p=0.05) Seroconversion (%/yr)

  33. Modality and Hepatitis C Pereira B. Kidney Int, 1997; 51:981-999

  34. 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

  35. 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

  36. 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

  37. Modality and EPO - Japan Shinzato T, et al, Kidney Int, 1999; 5:700-712

  38. Modality and EPO - Europe House AA, et al, Nephrol Dial Transplant, 1998; 13:1763-1769

  39. Modality and Transfusions House AA, et al, Nephrol Dial Transplant, 1998; 13:1763-1769

  40. 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

  41. 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.

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