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

1
What is the Role of Peritoneal Dialysis in
Optimising ESRD Patient Outcomes?
2
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
200011116-125
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 30334-42, 1997
Plt0.001
Patient Survival ()
10663 patients
Months
15
Comparing Survival of Integrated Care Patients
with HD Patients
Van Biesen JASN 2000 11116-25
PD to HD
HD
16
Possible Causes

• Better preservation of residual renal function in
  PD.
• Moist JASN 11556-64, 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 551553-9, 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
Preservation of residual renal function
Lysaght et al, ASAIO Trans, 1991 37598-604
19
Preservation of residual renal function
Lang et al, PDI 2152-57, 2001
20
plt0.05 plt0.01 plt0.001
Risk of RRF Loss
Moist JASN 11556-565, 2000









Odds Ratio Multivariate Analysis
1843 patients
21
What are the benefits of preserving residual
renal function?
Davies, S., 2000
Contributes to total solute clearance (1 ml/min
CrCl 10 liter CrCl/week)

• Provides endocrine functions
• Erythropoietin production
• Ca, phosphorus and vitamin D homeostasis

Improves ?2-microglobulin
and middle molecule clearance
Reduces Mortality
Improves QoL
Facilitates volume control
Allows for more liberal diet and fluid intake
Increases total Na removal
Improves nutritional status
22
Causes of RRF Preservation in PD

• Avoidance of Dehydration
• HD production of inflammatory mediators by blood
  contact
• McCarthy JASN 4367, 1993
• Lysaght ASAIO Trans 37598-604, 1991
• Better clearance of middle molecules, lipophilic
  and proteinbound toxins.

23
Serum CRP Values
Haubitz et al. PDI 16(2) 158-162, 1996
6000


plt0.01 vs. control plt0.01 vs. PD
5000
n21
4000
Serum CRP, ng/ml
3000


2000
n16
n24
1000
n33
0
Healthy Control
HD
CRF Without dialysis
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
Effect of CAPD Blood Pressure Control
Saldanha AJKD 1993 21184-188
20
Patients transferred from HD to PD (n 67)
15
10
5
Variation From Baseline
Weight
0
Blood Pressure
-5








-10





plt0.05
-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
19241-244
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
Dialysis Modality and Delayed Graft Function
Bleyer et al. J Am Soc Nephrol 10154-159, 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 10240-46, 1995
Plt0.001
Plt0.02

• 309 patients
• Brazil
• High background prevalence of Hepatitis B C
• Seroconversion partly related to blood
  transfusion (p0.05)

Seroconversion (/yr)
33
Modality and Hepatitis C
Pereira B. Kidney Int, 1997 51981-999
34
Why lower risk of HCV in PD?
Pereira KI 1997 51981-999

• 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 5700-712
38
Modality and EPO - Europe
House AA, et al, Nephrol Dial Transplant, 1998
131763-1769
39
Modality and Transfusions
House AA, et al, Nephrol Dial Transplant, 1998
131763-1769
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.