Optimal start in dialysis shows increased survival in patients with chronic kidney disease.

OBJECTIVE: To compare the survival among patients with chronic kidney disease who had optimal starts of renal replacement therapy, dialysis or hemodialysis, with patients who had suboptimal starts. METHODS: A retrospective cohort consisting of >18 year-old patients who started renal replacement therapy, using peritoneal dialysis or hemodialysis, in any public hospital or associated center of the Andalusian Public Health System, between the 1st of January of 2006 and the 15th of March of 2017. The optimal start was defined when all the following criteria were met: a planned dialysis start, a minimum of six-month follow-up by a nephrologist, and a first dialysis method coinciding with the one registered at 90 days. The information was obtained from the registry of the Information System of the Transplant Autonomic Coordination of Andalusia. RESULTS: A total of 10,692 patients were studied. 4,377 (40.9%) of these patients died. A total of 4,937 patients (46.17%) achieved optimal starts of renal replacement therapy and showed higher survival rates (HR 0.669; 95% CI 0.628-0.712) in the multivariate analysis of Cox regression model. CONCLUSIONS: Patients with an optimal start of renal replacement therapy have a greater survival than those who had a non-optimal start. Therefore, the necessary measures should be encouraged to increase the optimal start of the patient in dialysis.

Baseline Residual Kidney Function and Its Ensuing Rate of Decline Interact to Predict Mortality of Peritoneal Dialysis Patients.

BACKGROUND: Baseline residual kidney function (RKF) and its rate of decline during follow-up are purported to be reliable outcome predictors of patients undergoing Peritoneal Dialysis (PD). The independent contribution of each of these factors has not been elucidated. METHOD: We report a multicenter, longitudinal study of 493 patients incident on PD and satisfying two conditions: a glomerular filtration rate (GFR) ≥1 mL/minute and a daily diuresis ≥300 mL. The main variables were the GFR (mean of urea and creatinine clearances) at PD inception and the GFR rate of decline during follow-up. The main outcome variable was patient mortality. The secondary outcome variables were: PD technique failure and risk of peritoneal infection. The statistical analysis was based on a multivariate approach, placing an emphasis on the interactions between the two main study variables. MAIN RESULTS: Baseline GFR and its rate of decline performed well as independent predictors of both patient mortality and risk of peritoneal infection. These two main study variables maintained a moderate correlation with each other (r2 = 0.12, p<0.0005), and interacted clearly, as predictors of patient mortality. A low baseline GFR followed by a fast decline portended the worst survival outcome (adjusted HR 3.84, 95%CI 1.81-8.14, p<0.0005)(Ref. baseline GFR above median plus rate of decline below median). In general, the rate of decline of RKF had a greater effect on mortality than baseline GFR, which had no detectable effect on survival when the decline of RKF was slow (HR 1.17, 95% CI 0.81-2.22, p = 0.22). Conversely, a relatively high GFR at the start of PD still carried a significant risk of mortality, when RKF declined rapidly (HR 1.89, 95% CI 1.05-3.72, p = 0.028). CONCLUSION: The risk-benefit balance of an early versus late start of PD cannot be evaluated without taking into consideration the rate of decline of RKF. This circumstance may contribute to explain the controversial results observed at the time of evaluating the potential benefits of an early initiation of PD.

La diálisis peritoneal permite el trasplante cardíaco con éxito en paciente con insuficiencia cardíaca refractaria / Peritoneal dialysis allows successful cardiac transplantation in patients with refractory heart failure

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[Results of the cooperative study of Spanish peritoneal dialysis registries: analysis of 12 years of follow-up]. / Resultados del trabajo cooperativo de los registros españoles de diálisis peritoneal: análisis de 12 años de seguimiento.

INTRODUCTION AND OBJECTIVES: There is currently no registry that gives a complete and overall view of the peritoneal dialysis (PD) situation in Spain. However, a report on PD in Spain was developed for various conferences and meetings over several years from data provided by each registry in the autonomous communities and regions. The main objective of this study is to analyse this data in aggregate and comparatively to obtain a representative sample of the Spanish population on PD in recent years, in order that analysis and results in terms of demographic data, penetration of the technique, geographical differences, incidence and prevalence, technical aspects, intermediate indicators, comorbidity, and outcomes such as patient and technique survival may be extrapolated to the whole country. DESIGN, MATERIAL AND METHOD: Observational cohort study of autonomous PD registries, covering the largest possible percentage of the adult Spanish population (over 14 years of age) on PD, at least in the last decade (1999-2010), and in the largest possible geographical area in which we were able to recruit. A precise data collection strategy was followed for each regional registry. Once the information was received and clarified, they were added as aggregate data for statistical study. RESULTS: The regional registries that participated represent a total geographical area that encompasses 32,853,251 inhabitants over 14 years of age, 84% of the total Spanish population older than that age. The mean annual rate of incidents per million inhabitants (ppm) was variable (between 17.81 ppm in Andalusia and 29.90 ppm in the Basque Country), with a discrete and permanent increase in the overall PD incidence in Spain being observed in recent years. The mean annual prevalence per million population (ppm) was very heterogeneous (from 42 to 99 ppm). A mean progressive increase in the use of automated peritoneal dialysis (APD) was observed. The peritonitis rate was approximately one episode every 25-30 months/patient, with a slight decrease being observed in recent years. The causes of discontinuing PD were distributed fairly evenly between communities; almost a third was due to patient death (mean 28%), a third was due to renal transplantation (mean 39%) and a third was due to transfer to haemodialysis (technique failure: mean 32%). The main comorbidities were cardiovascular disease (30.2%) and diabetes mellitus (24.2%). The overall accumulated mean survival was 92.2%, 82.8%, 74.2%, 64.8% and 57% after one, two, three, four and five years respectively. There was significantly and independently worse survival for older patients and those with cardiovascular disease, patients with diabetes mellitus, those on continuous ambulatory peritoneal dialysis (vs. APD), those who started PD before 2004 (analysed in Andalusia and Catalonia), and patients with lower residual renal function at the start of PD (analysed in the Levante registry). Similarly, the technique survival has improved, showing a mean figure above 50% after 5 years. CONCLUSIONS: The incidence and prevalence of PD in Spain are growing moderately and in a generalised manner and continue to maintain an irregular distribution by autonomous community. Both patient and technique survival were greater than 50% after 5 years, with an improvement being observed in recent years, and are comparable to countries with better results in this treatment.

Compared decline of residual kidney function in patients treated with automated peritoneal dialysis and continuous ambulatory peritoneal dialysis: a multicenter study.

BACKGROUND: There is controversy concerning the compared rates of decline of residual kidney function (RKF) in patients treated with continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD). OBJECTIVES AND METHOD: Following an observational, multicenter design, we studied 493 patients initiating peritoneal dialysis (PD) in four different Spanish units. We explored the effect of the PD modality on the rate of decline of RKF and the probability of anuria during follow-up. We applied logistic regression for intention-to-treat analyses, and linear mixed models to explore time-dependent variables, excluding those affected by indication bias. MAIN RESULTS: Patients started on APD were younger and less comorbid than those initiated on CAPD. Baseline RKF was similar in both groups (p = 0.50). Eighty-seven patients changed their PD modality during follow-up. The following variables predicted a faster decline of RKF: higher (rate of decline) or lower (anuria) baseline RKF, younger age, proteinuria, nonprimary PD, use of PD solutions rich in glucose degradation products, higher blood pressure, and suffering peritonitis or cardiovascular events during follow-up. Overall, APD was not associated with a fast decline of RKF, but stratified analysis disclosed that patients with lower baseline RKF had an increased risk for this outcome when treated with this technique (HR: 2.26, 95% CI: 1.09-4.82, p = 0.023). Moreover, the probability of anuria during follow-up was overtly higher in APD patients (HR: 3.22, 95% CI: 1.25-6.69, p = 0.002). CONCLUSIONS: Starting PD patients directly on APD is associated with a faster decline of RKF and a higher risk of developing anuria than doing so on CAPD. This detrimental effect is more marked in patients initiating PD with lower levels of RKF.

Supervivencia de una estrategia de hemodiálisis no convencional tras 10 años de seguimiento / Survival rates in an unconventional haemodialysis strategy after a 10 year follow-up period

Antecedentes: A finales del siglo pasado, evidencias científicas de nivel II apoyaban una mayor supervivencia en técnicas de hemodiálisis (HD) alternativas a la HD convencional, cuya expectativa de vida a cinco años, en Europa, era inferior al 40 %. Desde el año 2000 nuestros pacientes incidentes se adscribieron a una estrategia de HD no convencional con el objetivo de evaluar su influencia en la supervivencia. Método: Estudio de cohorte realizado en 183 incidentes en HD entre 2000 y 2010. Al inicio de la HD se evaluaron antecedentes de enfermedad cardiovascular (EFCV) e índice de Charlson (ICh). Desde el año 2000 iniciamos la estrategia de HD no convencional que contenía protocolos de HD biocompatible, de alto flujo, objetivo de peso seco, esquema de tres sesiones semanales de cinco horas (HD 5 h x 3) y desde 2003, coexistiendo con el anterior, se inicia el esquema de sesiones de HD de cuatro horas en días alternos sin descanso de fin de semana (every other day dialysis: EODD) para incidentes de mayor riesgo. Resultados: De los 183 pacientes incidentes en el programa de HD, 84 se dializaron en esquema HD 5 h x 3 y 99 en EODD. La edad media fue de 60,6 ± 13,8 años, el 31,7 % eran mayores de 70 años, diabéticos el 43 %, con EFCV el 58,5 % y el ICh medio era de 4,55. La supervivencia (%) del primero al quinto año fue de 92, 82, 75, 62 y 55, con mediana de 5,65 años (intervalo de confianza [IC] 4,18-7,11) y media de 5,4 (IC 4,75-6,1). Conclusiones: La estrategia de HD no convencional que aplicamos a los pacientes incidentes en la técnica proporciona un buen resultado de supervivencia (AU)

Background: At the end of the last century, level II scientific evidence supported higher survival rates for alternative haemodialysis (HD) techniques when compared with conventional HD, whose five-year life expectancy in Europe was below 40%. Our incident patients participated in an unconventional HD strategy from the year 2000, with the aim of assessing its influence on survival. Method: A cohort study on 183 incident HD patients between 2000 and 2010. At the beginning of HD, we evaluated a history of cardiovascular disease (CVD) and Charlson index (ChI). In the year 2000, we began the unconventional HD strategy that included protocols of biocompatible high flux HD, dry weight target, a schedule of three weekly five hour sessions (HD 5h x 3) and from 2003, in combination with the foregoing, we began a schedule of four hour HD sessions on alternate days including weekends (every other day dialysis: EODD) for higher risk incident patients. Results: Of the 183 incident patients in the HD programme, 84 were dialysed in the 5hx3 HD schedule and 99 in EODD. The mean age was 60.6±13.8 years, 31.7% were older than 70, 43% were diabetic, with CVD sufferers at 58.5% and the mean ChI was 4.55. Survival (%) from the first to the fifth year was 92, 82, 75, 62 and 55, with a median of 5.65 years (confidence interval [CI] 4.18-7.11) and a mean of 5.4 (CI 4.75-6.1). Conclusions: The unconventional HD strategy that we applied to incident patients in the technique provided a good survival result (AU)

Survival rates in an unconventional haemodialysis strategy after a 10 year follow-up period.

BACKGROUND: At the end of the last century, level II scientific evidence supported higher survival rates for alternative haemodialysis (HD) techniques when compared with conventional HD, whose five-year life expectancy in Europe was below 40%. Our incident patients participated in an unconventional HD strategy from the year 2000, with the aim of assessing its influence on survival. METHOD: A cohort study on 183 incident HD patients between 2000 and 2010. At the beginning of HD, we evaluated a history of cardiovascular disease (CVD) and Charlson index (ChI). In the year 2000, we began the unconventional HD strategy that included protocols of biocompatible high flux HD, dry weight target, a schedule of three weekly five hour sessions (HD 5h x 3) and from 2003, in combination with the foregoing, we began a schedule of four hour HD sessions on alternate days including weekends (every other day dialysis: EODD) for higher risk incident patients. RESULTS: Of the 183 incident patients in the HD programme, 84 were dialysed in the 5hx3 HD schedule and 99 in EODD. The mean age was 60.6 ± 13.8 years, 31.7% were older than 70, 43% were diabetic, with CVD sufferers at 58.5% and the mean ChI was 4.55. Survival (%) from the first to the fifth year was 92, 82, 75, 62 and 55, with a median of 5.65 years (confidence interval [CI] 4.18-7.11) and a mean of 5.4 (CI 4.75-6.1). CONCLUSIONS: The unconventional HD strategy that we applied to incident patients in the technique resulted in good survival.

Logrando mejores resultados para la diálisis peritoneal en los últimos años / Achieving better results for peritoneal dialysis in recent years

Introducción: La supervivencia entre la hemodiálisis (HD) y la diálisis peritoneal (DP) son equivalentes, siendo los factores de comorbilidad asociados los que ejercen más influencia sobre la mortalidad. En los más recientes estudios, el pronóstico de la DP peritoneal ha mejorado proporcionalmente más que el de la HD, aunque esto no ha significado un aumento en la utilización de este tratamiento. Objetivos: Conocer si la DP en nuestro medio ha mejorado en el tiempo con respecto a sus resultados. Conocer la influencia de la comorbilidad y las características del tratamiento en los resultados finales. Métodos: Pacientes incidentes en DP en Andalucía entre 1999 y 2010. La cohorte se ha dividido en dos grupos: antes y después de 2004. Estadística: medias ± desviación estándar, frecuencias, test (..) (AU)

Introduction: Survival rates between haemodialysis (HD) and peritoneal dialysis (PD) are the same but the associated comorbidity factors have a great impact on mortality. In the most recent studies the prognosis for PD has improved more than that for HD, although this has not meant an increase in the use of this treatment. Objectives: To determine whether the PD has improved over time with respect to its outcomes in our community, and determine the influence of comorbidity and treatment characteristics on the final results. Methods: Incident patients undergoing DP in Andalusia between 1999 and (..) (AU)

Achieving better results for peritoneal dialysis in recent years.

INTRODUCTION: Survival rates between haemodialysis (HD) and peritoneal dialysis (PD) are the same but the associated comorbidity factors have a great impact on mortality. In the most recent studies the prognosis for PD has improved more than that for HD, although this has not meant an increase in the use of this treatment. OBJECTIVES: To determine whether the PD has improved over time with respect to its outcomes in our community, and determine the influence of comorbidity and treatment characteristics on the final results. METHODS: Incident patients undergoing DP in Andalusia between 1999 and 2010. The cohort was divided into two groups: before and after 2004. STATISTICS: mean ± standard deviation, frequency, chi-square test, Student's t-test, risk determination (95% confidence interval), Kaplan-Meyer, log-rank and multivariate Cox proportional hazards models. RESULTS: 1464 incident patients undergoing DP, 537 before 2004 and 927 after 2004. The baseline characteristics of both groups (age, diabetes) were similar, although the first group had more severe cardiovascular disease and higher Charlson comorbidity index. In the second period, more automatic PD and solutions of bicarbonate and icodextrin were used. The overall survival rate for patients was 55 months median and 65 mean. Within all subgroups (age, diabetes, cardiovascular disease, technique type) there was a greater tendency towards survival in the second period (the technique type, age and diabetes were found to be statistically significant variables). Age, cardiovascular disease, diabetes mellitus and incident cases before 2004 were all independent risk factors. This latter variable lost significance as bicarbonate or icodextrin-based solutions were introduced, which were independent risk factors. Technique survival showed a median of 68 months and a mean of 73 months. Dialysis solutions and the period when the DP was initiated were independent risk factors for the technique. CONCLUSIONS: DP has shown improved results in recent years; probably the new solutions are having a positive influence. As such PD should be implemented applying the criteria of effectiveness, free choice, efficiency and PD units should be fully developed within Nephrology Departments.