Propensity-Matched Mortality Comparison of Incident Hemodialysis and Peritoneal Dialysis Patients

Contemporary comparisons of mortality in matched hemodialysis and peritoneal dialysis patients are lacking. We aimed to compare survival of incident hemodialysis and peritoneal dialysis patients by intention-to-treat analysis in a matched-pair cohort and in subsets defined by age, cardiovascular disease, and diabetes. We matched 6337 patient pairs from a retrospective cohort of 98,875 adults who initiated dialysis in 2003 in the United States. In the primary intention-to-treat analysis of survival from day 0, cumulative survival was higher for peritoneal dialysis patients than for hemodialysis patients (hazard ratio 0.92; 95% CI 0.86 to 1.00, P = 0.04). Cumulative survival probabilities for peritoneal dialysis versus hemodialysis were 85.8% versus 80.7% (P < 0.01), 71.1% versus 68.0% (P < 0.01), 58.1% versus 56.7% (P = 0.25), and 48.4% versus 47.3% (P = 0.50) at 12, 24, 36, and 48 months, respectively. Peritoneal dialysis was associated with improved survival compared with hemodialysis among subgroups with age <65 years, no cardiovascular disease, and no diabetes. In a sensitivity analysis of survival from 90 days after initiation, we did not detect a difference in survival between modalities overall (hazard ratio 1.05; 95% CI 0.96 to 1.16), but hemodialysis was associated with improved survival among subgroups with cardiovascular disease and diabetes. In conclusion, despite hazard ratio heterogeneity across patient subgroups and nonconstant hazard ratios during the follow-up period, the overall intention-to-treat mortality risk after dialysis initiation was 8% lower for peritoneal dialysis than for matched hemodialysis patients. These data suggest that increased use of peritoneal dialysis may benefit incident ESRD patients.Hemodialysis and peritoneal dialysis differ profoundly, but randomized comparisons have so far proven impossible.¹ Despite obvious limitations, observational studies represent the next best design for survival comparisons. Although numerous studies have made peritoneal-dialysis-to-hemodialysis survival comparisons,^2–16 findings have not been entirely consistent.¹⁷ These survival comparisons are particularly salient in the United States, where mortality rates for hemodialysis patients are much higher than in Europe and in Japan,¹⁸ and peritoneal dialysis is used relatively little.^19,20 Because both modalities continue to evolve greatly from year to year, up-to-date survival comparisons may help inform the modality choices patients and physicians make when considering dialysis therapy. Comparative mortality studies of contemporary hemodialysis and peritoneal dialysis patients with similar comorbidity burdens are lacking.We used a matched-pair, retrospective cohort design to compare survival in adult patients initiating dialysis in the United States in 2003 with matching based on propensity of initial peritoneal dialysis use. Matching may reduce the influence of patients using one modality, who share few (if any) measured characteristics with patients using the other modality, because of contraindication or nonclinical forces.²¹ Our primary objective was to compare survival of incident dialysis patients, treated initially with hemodialysis or peritoneal dialysis, by intention-to-treat analysis in the matched-pair cohort. Secondary objectives were to compare survival across modalities in subsets defined by age, cardiovascular disease, and diabetes and to assess the sensitivity of inference to follow-up commencement (at dialysis initiation, at 90 days thereafter) and modality exposure definition (intention to treat, as-treated).     

Nutritional Treatment of Hemodialysis and Peritoneal Dialysis Patients

Abstract: The success of hemodialysis and peritoneal dialysis therapy is essentially dependent on adequate nutrition. Malnutrition represents one of the main factors in morbidity and mortality of dialysis patients. The main causes of malnutrition are insufficient energy intake, insufficient protein supply, loss of amino acids by dialysis, the uremic state of metabolism, catabolic stress of underlying diseases, and endocrinological disorders. For successful long-term chronic dialysis therapy, it is very important that patients be in an anabolic nutritional state when entering the dialysis program. In this paper, the nutritional needs of dialysis and peritoneal dialysis patients (fluid restriction, protein intake, energy supply, electrolyte balance, vitamin intake) are discussed to prevent the catabolic state.     

Preparation of Patients for Cadaveric Renal Transplantation1

Experience with renal homotransplantation during the last six years has made it apparent that the path from the terminal stages of chronic renal failure to renal transplantation is not always smooth and can expose the patient to a series of events which have a definite morbidity and mortality. This communication describes the various problems encountered in the period leading up to transplantation. In addition. the factors thought to be significant in their development and management will Be discussed.     

Polyomavirus BK Infection in End-stage Renal Disease: Analysis of Viral Replication in Patients on Hemodialysis or Peritoneal Dialysis

Patients in end-stage renal disease undergoing renal replacement treatment (ESRD-RRT) are considered immunocompromised. The hemodialysis (HD) or peritoneal dialysis (PD) procedures seem to produce alterations of the immune status. Interest in immunosuppression has increased due to the poliomavirus BK (BKV) infection. Our study evaluated the prevalence of BKV infection in ESRD-RRT patients and viral replication on HD or PD. From 2006 to 2011 we selected 58 patients (34 males) in ESRD-RRT for inclusion in our study. BKV replication was evaluated by qualitative real-time polymerase chain reaction. In ESRD-RRT patients, the prevalence of BKV replication on plasma was 21%. We identified two groups of patients according to the dialysis procedure: 36 patients on HD (HD group) and 22 on PD (PD group). BKV replication in the HD group was 33% (12 of 36) versus 0% (0 of 22) in the PD group. Different age, number of months on RRT, and preserved diuresis was observed in the HD versus PD groups. With our results we can speculate that BKV infection in ESRD-RRT patients is linked to factors involved in the uremia-related immune dysfunction but also to specific mechanisms related to the different RRTs. PD is an option that could be associated with a better transplant outcome for patients undergoing kidney transplantation.     

Female Sexual Dysfunction in Peritoneal Dialysis and Hemodialysis Patients

Background. Sexual dysfunction (SD) is a common problem in end-stage renal disease (ESRD). In contrast to basic and clinical research in the field of male SD, the sexual problems of women have received relatively little attention and are often under-treated. We evaluated sexual function in female ESRD patients using the validated Female Sexual Function Index (FSFI) and relation with QOL, depression, and some laboratory parameters. Methods. 117 ESRD patients (85 peritoneal dialysis [PD], 32 hemodialysis [HD], mean age 48.5 ± 13.9 years) were enrolled. All patients had been dialyzed (PD or HD) for more than three months. In addition, an age-matched married control group of 48 subjects (mean age 47.1 ± 12.7 years) were enrolled in the study. All patients were asked to complete three questionnaires of the FSFI, Beck Depression Index (BDI) and SF-36. Results. Female sexual dysfunction was found in 80 of the 85 peritoneal dialysis patients (94.1%) and all of the HD patients (100%), but in only 22 subjects of the control group (45.8%). A significant negative correlation was found between total FSFI score and age (r = ?0.288, p = 0.002), BDI score (r = ?0.471, p < 0.001), mental-physical component score of QOL (r = ?0.463, p < 0.001 and r = ?0.491, p < 0.001, respectively) in PD and HD patients. The rates of depression were 75.3, 43.8, and 4.2% in the PD and HD patients and control subjects, respectively. Conclusion. Female sexual dysfunction is common problem ESRD. This problem especially related with depression and QOL. Thus, sexual function should be evaluated in female subjects to determine its impact on quality of life.     

Comparison of Peritoneal Dialysis and Hemodialysis After Kidney Transplant Failure

Background

Patients with a failed kidney transplant represent a unique chronic kidney disease population that is increasing in number and is at high risk of morbidity and mortality. Among transplant-naïve patients, those treated with peritoneal dialysis (PD) show an early survival advantage compared with those treated with hemodialysis (HD). But any advantage of PD after allograft failure is unknown. The aim of this study was to investigate the clinical outcomes of patients with failed allografts according to the type of dialysis modality.

Method

We reviewed medical records of patients who initiated dialysis after kidney transplant failure from November 1982 to May 2011. Demographics features, clinical data, and survival outcomes were compared between PD and HD patients who had experienced allograft failure.

Results

The 182 patients with failed allografts showed the most common cause to be chronic rejection. The median duration of function before allograft failure was 74.0 months. After allograft failure, 145 (79.7%) patients returned to HD and 37 (20.3%) to PD. Twenty-three patients (12.6%) died over the median 69.1 months duration of follow-up. During the observation period, 16 HD (11%) and 7 PD (8.9%) patients died. The survival rates of PD patients at 1 year were 91.2% and 84.4%, respectively, at 1 and 3 years, and those of HD patients 94.8% and 88.9%. There was no significant difference in the survivals of the 2 groups.

Conclusions

The study suggests that the outcome of patients starting PD after kidney transplant failure was similar to those starting HD. Therefore, PD can be regarded to be a good treatment option for patients returning to dialysis after kidney transplant failure.     

Peritoneal Dialysis for Acute Renal Failure in Infants: A Comparison of Three Types of Peritoneal Access

Peritoneal access for peritoneal dialysis (PD) poses a significant problem in infants due to their small size and can result in considerable morbidity and occasional mortality. This study was carried out to compare the complications associated with three different types of PD catheters for intermittent PD. A total of 79 sessions of PD were given to 51 infants with acute renal failure. Twenty-nine infants received 1, 18 received 2 and 2 infants received 3 and 4 sessions of PD, respectively. For PD access an intravenous cannula was used in 36, stylet catheter in 18, and guide wire inserted femoral vein catheter in 25 procedures. Percentage reduction of serum creatinine per PD session was comparable in infants being dialysed with different types of PD access. Local puncture site and intraperitoneal bleed were associated with the use of a stylet catheter during 4 procedures each (22.2%). Catheter blockade was commonest with the intravenous cannula (22.2%), followed by guide wire inserted femoral vein catheter (16%), and was least with the stylet catheter (5.5%). Total mechanical complications were lower with guide wire inserted femoral vein catheter (16%) as compared to intravenous cannula (25%) and stylet catheter (66%) (p < 0.05). There were 4 episodes of peritonitis (5.0%), 3 bacterial and 1 fungal. Although peritonitis was more common with intravenous cannula (8.3%) than guide wire inserted catheter (4%) and stylet catheter (nil), the difference was not statistically significant. Total complications including mechanical and infective were least with guide wire inserted femoral vein catheter (20%), followed by intravenous cannula (33%) and stylet catheter (66%) (p < 0.05). Of 51 infants, 20 died (39.0%). The PD procedure per se resulted in mortality in 2 cases, 1 because of massive intraperitoneal bleed due to stylet induced injury of an intra abdominal blood vessel and the other due to fungal peritonitis. To conclude, of the three types of access for intermittent PD, complications related to the PD procedure are the least with guide wire inserted femoral vein catheter.     

The Affecting Factors and Comparison of Tuberculin Skin Test in Peritoneal Dialysis and Hemodialysis Patients

Compared with the general population, patients with chronic renal failure have increased tuberculosis (TB) prevalence and mortality rates. In this study, we aimed to investigate tuberculin skin test (TST) positivity rates in hemodialysis (HD) and peritoneal dialysis (PD) patients and the factors influencing TST positivity. Ninety-two HD patients and 44 PD patients who had been on HD and PD treatment for at least 3 months were recruited into the study. TST was administered in all patients. Positivity was defined as an induration diameter >10 mm. At least 5 mm of induration following skin testing together with a chest radiography indicating previous infection was defined as latent TB infection. TST positivity rates, diameter of TST indurations, and serum albumin levels in HD patients were higher than the PD patients. TST induration size was not correlated with any other parameters in both HD and PD groups. TST-positive patients had higher albumin levels and lower leukocyte count than the TST-negative patients. In TST-positive patients, albumin level was correlated with the duration of dialysis but TST induration size was not correlated with the lymphocyte count and albumin level. In our study, TST positivity of patients was found in 30.4% of HD patients, 9% of PD patients, and 23.5% of total patients. It is still recommended to use TST for the screening test of TB. We found a significant relationship between TST and albumin level. It should be remembered that TST response may be lower in PD patients, especially in cases in which TB is suspected.     

Paired Analysis of Outcomes After Kidney Transplantation in Peritoneal and Hemodialysis Patients

Background

The impact of dialysis modality before kidney transplantation (hemodialysis or peritoneal dialysis) on outcomes is not clear. In this study we retrospectively analyzed the impact of dialysis modality on posttransplant follow-up.

Occult HBV Infection in Continuous Ambulatory Peritoneal Dialysis and Hemodialysis Patients

Aim. Occult hepatitis B virus (HBV) infection can be defined as the presence of HBV DNA in the liver and/or blood in the absence of detectable serum hepatitis B surface antigen (HBs Ag). There is a high prevalence of occult HBV infection in dialysis patients. This study investigated the prevalence of occult HBV infection in continuous ambulatory peritoneal dialysis (CAPD) and hemodialysis (HD) patients and compared the prevalence of occult HBV infection in dialysis patients either with or without hepatitis C virus (HCV) infection.?Methods.?In this cross-sectional study, 71 CAPD patients and 71 HD patients were evaluated. HBV DNA testing was performed by polymerase chain reaction (PCR). We recorded general characteristics of the patients, duration of dialysis, HBs Ag, antibody to hepatitis B surface antigen (anti-HBs), antibody to hepatitis B core antigen (anti-HBc), anti-HCV antibody (anti-HCV), HCV RNA, serum alanine aminotransferase (ALT), and aspartate aminotransferase levels (AST).?Results.?Twelve (16.9%) of the 71 HD patients and seven (9.8%) of the 71 CAPD patients were HBV DNA-positive. A statistically significant difference was not observed in the groups. Anti-HCV was negative and AST and ALT levels were normal in all of the HBV-DNA positive patients. Viral loads were low in both groups. Conclusion. This is the first study that analyzes occult HBV prevalence in CAPD patients. We conclude that the prevalence of the occult HBV may be common in CAPD patients as in HD patients, and HCV positivity is not a contributing factor to occult HBV infection in dialysis patients.     

Attitude of Hemodialysis Patients Toward Renal Transplantation: A Moroccan Interregional Survey

Introduction

Kidney transplantation (KT) is considered the treatment of choice for many patients with severe chronic kidney disease because quality of life and survival are often better than in patients who undergo dialysis. This study assessed patients' knowledge and attitudes regarding KT.

Patients and Methods

A total of 2066 hemodialysis patients were investigated as part of the ARTEMIS (Attitude Toward Renal Transplantation and Eligibility Among Dialysis Patients in a Moroccan Interregional Survey) study.

Results

Patients' mean age was 52.9 years, and the mean duration of hemodialysis was 55.3 months. Among these patients, 73.3% would like to undergo transplantation. Among the subjects wishing to be transplanted, 75.7% would accept the graft from a living or a cadaveric donor; 17.8% would refuse transplantation from a related living donor; and 6.5% would reject organs from donors after brain death. Approximately 17% of patients have a potential related living donor. The main motivating factor for KT was fluid restriction and diet constraints (43.3%). One third of patients believe that Islam does not allow organ donation from a related living donor, and almost one half think that it is prohibited from a brain-dead donor. Independent factors affecting patients' attitude toward KT were young age, male gender, persistence of residual diuresis, availability of a related living donor, and better information on the subject of transplantation.

Conclusions

To improve hemodialysis patients' accessibility to KT, patients, their families, and other support providers need better information. Awareness campaigns are needed to promote organ donation.     

Association between Body Composition and Frailty among Prevalent Hemodialysis Patients: A US Renal Data System Special Study

Studies of frailty among patients on hemodialysis have relied on definitions that substitute self-reported functioning for measures of physical performance and omit weight loss or substitute alternate criteria. We examined the association between body composition and a definition of frailty that includes measured physical performance and weight loss in a cross-sectional analysis of 638 adult patients receiving maintenance hemodialysis at 14 centers. Frailty was defined as having three of following characteristics: weight loss, weakness, exhaustion, low physical activity, and slow gait speed. We performed logistic regression with body mass index (BMI) and bioelectrical impedance spectroscopy (BIS)-derived estimates of intracellular water (ICW), fat mass, and extracellular water (ECW) as the main predictors, and age, sex, race, and comorbidity as covariates. Overall, 30% of participants were frail. Older age (odds ratio [OR], 1.31 per 10 years; 95% confidence interval [95% CI], 1.14 to 1.50), diabetes (OR, 1.65; 95% CI, 1.13 to 2.40), higher fat mass (OR, 1.18; 95% CI, 1.02 to 1.37), and higher ECW (OR, 1.33; 95% CI, 1.20 to 1.47) associated with higher odds of frailty. Higher ICW associated with lower odds of frailty (OR, 0.80 per kg; 95% CI, 0.73 to 0.87). The addition of BMI data did not change the area under the receiver operating characteristics curve (AUC; AUC=0.66 versus 0.66; P=0.71), but the addition of BIS data did change the AUC (AUC=0.72; P<0.001). Thus, individual components of body composition but not BMI associate strongly with frailty in this cohort of patients receiving hemodialysis.Patients on dialysis frequently experience protein energy wasting or loss of protein mass and energy stores, which is likely multifactorial.¹ It has recently been appreciated that the same disorders that underlie protein energy wasting as well as muscle wasting itself are also commonly associated with frailty.^2–4 Although frailty is generally considered to be a geriatric syndrome, individuals with chronic diseases, such as CKD, may be at risk for premature frailty.^5,6 In fact, as many as two thirds to three quarters of patients new to dialysis may be frail by definitions that rely on patient self-report of physical functioning and omit weight loss or substitute alternate criteria for wasting (6,⁷

Table 1.

Definitions of frailty adapted from the Cardiovascular Health Study definition

尸体肾移植1011例次的回顾与分析

１９７８年６月至１９９３年１２月，我院完成同种异体肾移植９６９例，１０１１例次。人／肾总存活率１年为８９．２％／７８．７％；３年为８２．０％／７４．７％；５年为６７．０％／５８．４％；存活１０年以上已有１２例，最长存活已达１５年。１５昕的经验表明：（１）高质量取肾与植肾手术尤为重要；（２）由于环孢素在体内的吸收和代谢存在着明显个体差异及受者免疫反应强度不同，监测环孢素血浓度甚为重要；（３）应坚持Ａ