Caring for Older Patients on Peritoneal Dialysis at End of Life.

End of life is the last phase of life, not merely the last few days. For many older patients on peritoneal dialysis (PD), the end-of-life phase commences with the start of dialysis. The principal aim of management of this phase should be optimizing the quality of life of the patient. Evidence suggests that patients on dialysis mostly want involvement in decisions at this stage, but most do not have the opportunity to do so. Management should therefore include discussions with the patient and their family to determine lifestyle goals, treatment wishes, and ceilings of care (including resuscitation and dialysis withdrawal). Care should also include symptom identification and management, psychosocial support, and adaptation of dialysis to the ability and needs of the patient. By doing this, quality of life at end of life is achievable.

[Choice of a dialysis method for patients with kidney failure]. / Choix d'une méthode de dialyse par les malades insuffisants rénaux.

The principal options for treatment of end-stage renal disease are hospital, out-center, self-or home hemodialysis or continuous ambulatory or automated peritoneal dialysis. Hemodialysis and peritoneal dialysis were long considered competitive methods, but they have become complementary and the same patient can use them successively at different life stages. The choice of technique usually depends on family, personal, social and work factors, rather than the medical situation. The healthcare team provides guidance to the patient in making this choice. The choice of treatment is optimal when the referral is early.

Survival of functionally anuric patients on automated peritoneal dialysis: the European APD Outcome Study.

The European APD Outcome Study (EAPOS) is a 2-yr, prospective, multicenter study of the feasibility and clinical outcomes of automated peritoneal dialysis (APD) in anuric patients. A total of 177 patients were enrolled with a median age of 54 yr (range, 21 to 91 yr). Previous median total time on dialysis was 38 mo (range, 1.6 to 259 mo), and 36% of patients had previously been on hemodialysis for >90 d. Diabetes and cardiovascular disease were present in 17% and 46% of patients, respectively. The APD prescription was adjusted at physician discretion to aim for creatinine clearance (Ccrea) >/=60 L/wk per 1.73 m(2) and ultrafiltration (UF) >/=750 ml/24 h during the first 6 mo. Baseline solute transport status (D/P) was determined by peritoneal equilibration test. At 1 yr, 78% and 74% achieved Ccrea and UF targets, respectively; median drained dialysate volume was 16.2 L/24 h with 50% of patients using icodextrin. Baseline D/P was not related to UF achieved at 1 yr. At 2 yr, patient survival was 78% and technique survival was 62%. Baseline predictors of poor survival were age (>65 yr; P = 0.006), nutritional status (Subjective Global Assessment grade C; P = 0.009), diabetic status (P = 0.008), and UF (<750 ml/24 h; P = 0.047). Time-averaged analyses showed that age, Subjective Global Assessment grade C and diabetic status predicted patient survival with UF the next most significant variable (risk ratio, 0.5/L per d; P = 0.097). Baseline Ccrea, time-averaged Ccrea, and baseline D/P had no effect on patient or technique survival. This study shows that anuric patients can successfully use APD. Baseline UF, not Ccrea or membrane permeability, is associated with patient survival.