Helen Hurst

Outcomes of Peritoneal Dialysis Patients and Switching to Hemodialysis: A Competing Risks Analysis

♦ Background: We performed a review of a large incident peritoneal dialysis cohort to establish the impact of current practice and that of switching to hemodialysis. ♦ Methods: Patients starting peritoneal dialysis between 2004 and 2010 were included and clinical data at start of dialysis recorded. Competing risk analysis and Cox proportional hazards model with time-varying covariate (technique failure) were used. ♦ Results: Of 286 patients (median age 57 years) followed for a median of 24.2 months, 76 were transplanted and 102 died. Outcome probabilities at 3 and 5 years respectively were 0.69 and 0.53 for patient survival (or transplantation) and 0.33 and 0.42 for technique failure. Peritonitis caused technique failure in 42%, but ultrafiltration failure accounted only for 6.3%. Davies comorbidity grade, creatinine and obesity (but not residual renal function or age) predicted technique failure. Due to peritonitis deaths, technique failure was an independent predictor of death hazard. When successful switch to hemodialysis (surviving more than 60 days after technique failure) and its timing were analyzed, no adverse impact on survival in adjusted analysis was found. However, hemodialysis via central venous line was associated with an elevated death hazard as compared to staying on peritoneal dialysis, or hemodialysis through a fistula (adjusted analysis hazard ratio 1.97 (1.02 - 3.80)). ♦ Conclusions: Once the patients survive the first 60 days after technique failure, the switch to hemodialysis does not adversely affect patient outcomes. The nature of vascular access has a significant impact on outcome after peritoneal dialysis failure.

INITIAL OBSERVATIONS USING A NOVEL “CINE” MAGNETIC RESONANCE IMAGING TECHNIQUE TO DETECT CHANGES IN ABDOMINAL MOTION CAUSED BY ENCAPSULATING PERITONEAL SCLEROSIS

Encapsulating peritoneal sclerosis (EPS) is an uncommon complication of peritoneal dialysis (PD), with high mortality and morbidity. The peritoneum thickens, dysfunctions, and forms a cocoon that progressively “strangulates” the small intestine, causing malnutrition, ischemia, and infarction. There is as yet no reliable noninvasive means of diagnosis, but recent developments in image analysis of cine magnetic resonance imaging for the recognition of adhesions offers a way forward. We used this protocol before surgery in 3 patients with suspected EPS. Image analysis revealed patterns of abdominal movement that were markedly different from the patterns in healthy volunteers. The volunteers showed marked movement throughout the abdomen; in contrast, movement in EPS patients was restricted to just below the diaphragm. This clear difference provides early “proof of principle” of the approach that we have developed.

Length of time on peritoneal dialysis and encapsulating peritoneal sclerosis : position paper for ISPD : 2017 update

Imperial College Renal and Transplant Centre,1 Hammersmith Hospital, London, UK; University Health Network and the University of Toronto,2 Toronto, ON, Canada; Renal Division,3 Ghent University Hospital, Ghent, Belgium; Kidney Research Center,4 Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Yale School of Medicine,5 New Haven, CT, USA; Central Manchester and Manchester Children’s NHS Foundation Trust,6 Manchester, UK; Department of Nephrology,7 University of Queensland at Princess Alexandra Hospital, Brisbane, Australia; Tsuchiya General Hospital,8 Faculty of Medicine, Hiroshima University, Japan; Institute for Applied Clinical Sciences,9 Keele University, Stoke-on-Trent, UK; Pontificia Universidade Catolica do Parana,10 Curitiba, Parana, Brazil; Division of Nephrology,11 Cliniques universitaires Saint-Luc, Brussels, Belgium, et Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels, Belgium; and St James’s University Hospital,12 Leeds, UK ISPD GUIDELINES/RECOMMENDATIONS

The Needs of Older Patients for Peritoneal Dialysis: Training and Support at Home.

Chronic kidney disease (CKD) in all its stages has become an important problem for older patients, stage 3 – 5 is expected to happen in 25 to 30% of the population, and a higher prevalence can be found in residential care and nursing homes, affecting the demand for patient education. Although older patients are able and keen to learn, there are specific needs that must be addressed. The focus of this paper is to review the demands to train and maintain older patients on peritoneal dialysis (PD) at home.

Encapsulating peritoneal sclerosis following renal transplantation despite tamoxifen and immunosuppressive therapy

Encapsulating peritoneal sclerosis (EPS) is a rare disease in patients who have undergone peritoneal dialysis (PD). We report a case of EPS following renal transplantation that highlights important clinical issues. Initially, a presumptive diagnosis of EPS was made following surgical and pathological findings at the time of cholecystectomy. CT imaging at this time did not confirm the diagnosis. The patient continued PD and commenced tamoxifen. Prior to and immediately following transplantation, further CT imaging demonstrated no evidence of EPS. Acute bowel obstruction occurred 5 months post-transplantation and a diagnosis of EPS was made both clinically and on CT imaging, despite immunosuppression and tamoxifen. The role of these therapies in managing EPS post-transplant is discussed, in addition to the need for a high index of clinical suspicion to make the diagnosis.

A Study to Inform the Design of a National Multicentre Randomised Controlled Trial to Evaluate If Reducing Serum Phosphate to Normal Levels Improves Clinical Outcomes including Mortality, Cardiovascular Events, Bone Pain, or Fracture in Patients on Dialysis.

Background. Retrospective, observational studies link high phosphate with mortality in dialysis patients. This generates research hypotheses but does not establish “cause-and-effect.” A large randomised controlled trial (RCT) of about 3000 patients randomised 50 : 50 to lower or higher phosphate ranges is required to answer the key question: does reducing phosphate levels improve clinical outcomes? Whether such a trial is technically possible is unknown; therefore, a study is necessary to inform the design and conduct of a future, definitive trial. Methodology. Dual centre prospective parallel group study: 100 dialysis patients randomized to lower (phosphate target 0.8 to 1.4 mmol/L) or higher range group (1.8 to 2.4 mmol/L). Non-calcium-containing phosphate binders and questionnaires will be used to achieve target phosphate. Primary endpoint: percentage successfully titrated to required range and percentage maintained in these groups over the maintenance period. Secondary endpoints: consent rate, drop-out rates, and cardiovascular events. Discussion. This study will inform design of a large definitive trial of the effect of phosphate on mortality and cardiovascular events in dialysis patients. If phosphate lowering improves outcomes, we would be reassured of the validity of this clinical practice. If, on the other hand, there is no improvement, a reassessment of resource allocation to therapies proven to improve outcomes will result. Trial Registration Number. This trial is registered with ISRCTN registration number ISRCTN24741445.

Does Shared Decision-Making Provide an Opportunity to Improve the Outcome of Peritoneal Dialysis Catheter Insertion?

S decision-making” describes patients and health care professionals working in partnership to select investigations or management options based on clinical evidence and the informed preferences of patients (1). The value of effective multidisciplinary teamwork is widely recognized, but the role of patients themselves in improving outcomes is often underemphasized. Evidence from a range of chronic diseases demonstrates the benefit of greater patient involvement. For example, it would be unimaginable to manage diabetes successfully without patient education and engagement. Indeed, the Dose Adjustment for Healthy Eating program has demonstrated that empowering patients to manage their diabetes through structured education leads to improvements in measurable outcomes such as glycosylated hemoglobin (2). However, not every intervention aimed at greater patient involvement leads to improved outcomes [reviewed by de Silva (3)], and the chance of success appears to increase when multiple approaches are used together. Thus, the combination of written information with educational courses and motivational interviewing, backed up by patient-held records and self-monitoring, may all be necessary to have the greatest impact (Figure 1). At present, the evidence is insufficient to support firm conclusions about the most effective interventions to increase adoption by health care professionals of shared decision-making. Training for health care professionals is important, as might be the implementation of patientmediated interventions such as decision aids (4). It can be argued that peritoneal dialysis (PD) has led the way with the expert patient concept—clearly demonstrating that patients can be trained to take on their own care very successfully. Day-to-day clinical experience provides support for the view that a variety of information-giving approaches works best to reach a high standard of patient education (5). In this issue of Peritoneal Dialysis International, Leslie Wong and colleagues from the University of Washington report a prospective observational study, conducted during 2010, of patient recollection of perioperative practices and education concerning PD catheter placement. This area of investigation is important because the successful placement of PD access is central to patients entering the therapy; unnecessary complications are distressing for patients and lead to inefficient use of health care resources. The study was designed as a quality improvement initiative conducted in a group of private and academic nephrologists in the Seattle area. It set out to determine the extent of the evaluation, education, and care related to PD catheter placement, with a focus on how consistently patients were involved in preparation and perioperative management. Quality improvement initiatives have received a great deal of attention in health care, applying principles from industry to drive change and to improve the quality of services (6–7). Certain key principles should be followed when applying a quality improvement initiative, and Wong and colleagues certainly attempted to provide a patientfocused approach. Arguably, their study constituted a survey rather than a true quality improvement initiative, which would have required several well-defined components, including understanding the patient pathway and processes, and involving patients and staff alike (8). The domains of the questionnaire used in the study were based on components of the International Society for Peritoneal Dialysis (ISPD) guideline (9) and included such aspects as preoperative evaluation, planning the location of the exit site with the patient, preoperative nasal swab, and postoperative problem-solving. However, it is not clear from the paper whether existing practice and patient pathways and processes were evaluated as a baseline. Using the ISPD guideline as best-practice guidance was sensible; however, knowledge of existing Figure 1 — Continuum of strategies to suppor t selfmanagement. Reproduced from de Silva (3), used with permission.

Towards Detecting the “Adhesive Cocoon” of Encapsulating Peritoneal Sclerosis (Eps) by Cine-MRI: A Pilot Study

Introduction Peritoneal dialysis (PD) is the preferred method for long-term management of patients with end-stage renal failure. Over time, peritoneal fibrosis leads to dysfunction and in some to encapsulating peritoneal sclerosis (EPS). This is characterised by a diffuse visceral film forming a tightening cocoon, which ultimately ‘strangles’ its contents. The patients present with bowel obstruction leading to eventual small intestinal failure, ischaemia and infarction. Surgery can be curative. There is no reliable method for early detection. Recent novel developments based on an MR image analysis method have permitted detection of adhesions from Crohn9s disease and surgery, which typically are focal or multifocal. EPS, being adhesions forming a ‘cocoon’, is also likely to disrupt movement but with a different pattern. We hypothesised it may be detectable with our system. This pilot is a proof-of-principle investigation. MR video-loop of abdominal examination in health shows remarkably smooth movement. Traditional MRI concentrates on structure; by focusing on movement instead we noticed disruption due to Crohn9s and surgical adhesions. Methods The Sheffield Image Registration Toolkit was used to develop software for more rapid review. Images are acquired at different stages in the respiratory cycle; registration links each point in an image to its corresponding point in another. Data are displayed as vectors and contours. In an earlier study standard dynamic non-contrast MR images were obtained from healthy volunteers; the movement pattern could be classified as ‘smooth’ (normal) or ‘disrupted’ (perhaps indicating adhesions). Three patients switched from PD to haemodialysis awaiting surgery with suspected EPS were also investigated. Results Surgical findings confirmed EPS. 18 volunteers were studied; representative processed sagittal images from 2 volunteers and 2 patients are shown. There is a striking difference in movement pattern. In health movement is marked in the upper abdomen but still very noticeable in the lower part. In EPS movement is restricted to the upper abdomen. This is shown by the distribution of the red contours which signify maximum movement (and blue the least). Conclusion This pilot study suggests dynamic cine-MRI coupled with advanced image analysis of movement can detect disruption due to an EPS cocoon. The method offers an approach in PD patients for early detection of disordered abdominal movement, signifying potential dialysis failure.