Peter G. Blake

Choosing peritoneal dialysis reduces the risk of invasive access interventions

BACKGROUND Patients choosing between hemodialysis (HD) and peritoneal dialysis (PD) should be well informed of the risks and benefits of each modality. Invasive access interventions are important outcomes because frequent interventions lower patients quality of life and consume limited resources. The objective of this study was to compare the risk of access interventions between the two modalities. METHODS Three hundred and sixty-nine incident chronic dialysis patients were prospectively enrolled at four Canadian centers that were eligible for both modalities, received at least 4 months of pre-dialysis care and started dialysis electively as an outpatient. Two hundred and twenty-four (61%) chose PD and 145 (39%) chose HD. Patients were followed for an average of 1.3 years (range 0.07-3.6 years). RESULTS In the PD group, there were fewer access interventions (2.5 versus 3.1 interventions per patient, adjusted odds ratio of 0.79 for PD versus HD, P = 0.005) and a lower intervention rate (2.3 versus 1.9 per patient-year, adjusted rate ratio of 0.81 for PD versus HD, P = 0.04). PD catheters were less likely to experience primary failure (4.6 versus 32%, P < 0.0001), showed a trend toward lower intervention rates during use (0.8 versus 1.2 per patient-year, P = 0.06), and had equal patency compared to fistulae (1-year patency of 84 versus 88%, P = 0.48). Patients managed exclusively with HD catheters (28% of the HD group) required 1.7 interventions per patient and an intervention rate of 1.9 per patient-year. CONCLUSION Patients who choose PD require fewer access interventions to maintain dialysis access than patients choosing HD.

The risks of vascular access

Fatal vascular access hemorrhage is considered a rare complication of hemodialysis (HD). Ellingson et al. indicate otherwise, and their data suggest that it causes 0.4-1.6% of deaths in US HD patients. It is more common with grafts than fistulas, and many victims have had previous access hemorrhages. The widespread presumption that a fistula is the best, and a cuffed catheter the worst, access for HD patients needs reassessment, particularly in older, sicker patients.

A Patient-Centered Approach to Hemodialysis Vascular Access in the Era of Fistula First

The primary vascular access options for the hemodialysis population are arteriovenous fistulas (AVF), arteriovenous grafts, and cuffed central venous catheters (CVC). AVFs are associated with the most favorable outcomes with respect to complications, interventions required to maintain functionality and patency, and overall cost. These population‐based outcomes, in conjunction with the efforts of the Fistula First Breakthrough Initiative, have propelled the prevalence of AVFs in the US hemodialysis population. While this endeavor remains steadfast in assuring the continued dominance of this policy for AVF preference, it fails to take into account a subset of the dialysis population who will fail to see the benefits of an AVF. This subset of patients may include the elderly, those with poor vasculature anatomy, those with slowly progressive CKD who are more likely to die than progress to ESRD, and those with an overall poor long‐term prognosis and shortened life expectancy. Thus, in an effort to avoid numerous unnecessary surgical and interventional procedures with minimal to no gains in clinical outcomes, an individualized patient approach must be adopted. The Centers for Medicare and Medicaid Services–instituted quality incentive program is designed to reward high AVF prevalence while also penalizing high CVC prevalence. The current model is devoid of case‐based adjustment, thus penalties are disbursed to dialysis providers in accordance with a “one‐size‐fits‐all” fistula only approach. The most suitable access for a patient remains the one that takes into account the characteristics unique to the individual patient with a primary focus on patient comfort, satisfaction, quality of life, and clinical outcomes.

Drain pain, overfill, and how they are connected.

Drain pain and overfill are two complications of peritoneal dialysis (PD) that get very little attention in the published literature. A “PubMed” search reveals no articles about PD with ‘drain pain’ in the title and only one addressing ‘overfill’ in the sense of an excessive intraperitoneal dialysate volume (1). Are these complications both rare? Or are they trivial curiosities not worthy of more clinical attention? This commentary will argue that one of the two is very common, that both need to be understood better, and that they have recently become related in an unforeseen way.

Maternal, pregnancy and fetal outcomes in de novo anti-glomerular basement membrane antibody disease in pregnancy: a systematic review

Background Outside of pregnancy, anti-glomerular basement membrane (GBM) antibody disease is associated with significant morbidity and mortality. However, there is limited knowledge regarding de novo anti-GBM disease in pregnancy. Methods A systematic review was performed to identify maternal, pregnancy and fetal outcomes in de novo anti-GBM disease in pregnancy. Studies were selected from PubMed, EMBASE, Cochrane Library databases and conference proceedings, without language restriction. Results Data from eight patients were derived from seven case reports and one unpublished case. Most (6/8) patients presented after the first trimester. During pregnancy, acute kidney injury (5/8), anemia (5/8), hematuria (8/8) and proteinuria (8/8) were common. When hemodialysis was required antepartum (5/8), renal function recovery to independence of renal replacement was unlikely (2/5). While pulmonary involvement was common (5/8), no permanent damage was reported (0/8). The majority of cases ended in live births (6/8) although prematurity (6/6), intrauterine growth restriction (2/6), small for gestational age (4/6) and complications of prematurity (1/6) were common. When anti-GBM levels were tested in the living newborn, they were detectable (2/5), but no newborn renal or lung disease was reported (0/6). Complications in pregnancy included gestational diabetes (3/8), hyperemesis gravidarum (2/8) and preeclampsia (2/8). Conclusions Live births can be achieved in de novo anti-GBM disease in pregnancy, but are commonly associated with adverse maternal, pregnancy and fetal outcomes. Only with awareness of common presentations, and management strategies can outcomes be optimized.

Dialysis: Peritoneal dialysis vs hemodialysis: time to end the debate?

Uncertainty exists over whether hemodialysis or peritoneal dialysis is the modality associated with better survival in patients with end-stage renal disease. Mehrotra and colleagues have shown that survival rates have improved more with peritoneal dialysis than with hemodialysis in more recent cohorts of US patients starting dialysis and that, overall, the two modalities have very similar 5-year mortality rates.

Practical Guide to Measuring Adequacy of Dialysis

Measurement of adequacy of small solute clearance on hemodialysis (HD) and peritoneal dialysis (PD) is important. In HD, formal urea kinetic modelling (UKM) is recommended because it is theoretically more accurate than the urea reduction ratio (URR) and because it allows prospective selection of an adequate prescription. However, the URR is simpler and has an important role to play. Precise attention to the methodology of sampling the post-HD blood urea is important. In PD, both Kt/V and creatinine clearance should be measured, and the main concerns relate to logistic problems in collection and processing of dialysate samples. In both HD and PD, a well-defined standardized methodology for measuring adequacy indices should be in place in each dialysis unit.

Is the peritoneal dialysis biocompatibility hypothesis dead

The peritoneal dialysis (PD) biocompatibility hypothesis is that conventional PD solutions with high levels of glucose degradation products (GDPs), glucose and lactate, and low pH cause morphological and functional damage to the peritoneal membrane and that this damage may be attenuated by biocompatible solutions. Functional findings from randomized trials have not supported this hypothesis, and now new data from a large European pediatric peritoneal biopsy study provide a morphologic correlate for this. The implications are discussed.

EARLY PERITONITIS IN A LARGE PERITONEAL DIALYSIS PROVIDER SYSTEM IN COLOMBIA.

♦ Background: Peritonitis is the most important complication of peritoneal dialysis (PD), and early peritonitis rate is predictive of the subsequent course on PD. Our aim was to calculate the early peritonitis rate and to identify characteristics and predisposing factors in a large nationwide PD provider network in Colombia. ♦ Methods: This was a historical observational cohort study of all adult patients starting PD between January 1, 2012, and December 31, 2013, in 49 renal facilities in the Renal Therapy Services in Colombia. We studied the peritonitis rate in the first 90 days of treatment, its causative micro-organisms, its predictors and its variation with time on PD and between individual facilities. ♦ Results: A total of 3,525 patients initiated PD, with 176 episodes of peritonitis during 752 patient-years of follow-up for a rate of 0.23 episodes per patient year equivalent to 1 every 52 months. In 41 of 49 units, the rate was better than 1 per 33 months, and in 45, it was better than 1 per 24 months. Peritonitis rates did not differ with age, ethnicity, socioeconomic status, or PD modality. We identified high incidence risk periods at 2 to 5 weeks after initiation of PD and again at 10 to 12 weeks. ♦ Conclusion: An excellent peritonitis rate was achieved across a large nationwide network. This occurred in the context of high nationwide PD utilization and despite high rates of socioeconomic deprivation. We propose that a key factor in achieving this was a standardized approach to management of patients.