Dialysis in diabetic patients: hemodialysis and peritoneal dialysis. Pros and cons

Both hemodialysis (HD) as well as peritoneal dialysis (PD), are efficient renal replacement therapies in uremic patients with and without diabetes. PD is less expensive dialysis modality and may provide a survival advantage over hemodialysis in first 2 to 4 years of treatment. Chronic ambulatory peritoneal dialysis (CAPD) as well as Continuous Cycler-Assisted Peritoneal Dialysis (CCPD) have additional advantages in patients with diabetes. PD therapy will be better tolerated than HD, the blood pressure is more stable and vascular access is not necessary. Preserving residual renal function (RRF) is of paramount importance to prolong the survival outcomes in PD patients. In insulin-dependent diabetic patients intraperitoneal insulin substitution can be used. The development of new, more biocompatible PD solutions holds promise for the future. Nevertheless, in many countries HD is further more favoured in the treatment of patients with ESRD.     

Dialysis as bridge therapy for renal transplantation: single center experience, a comparison of hemodialysis and continuous ambulatory peritoneal dialysis

BACKGROUND: Kidney transplantation is the most ideal treatment in renal replacement therapy for patients with end-stage renal disease. However, the prevalence of transplantation is extremely low and most patients with ESRD should continue dialysis for their whole life. Recently, high transposition rate of renal transplantation from peritoneal dialysis (PD) was reported, however, it was unclear whether a difference in dialytic modality can influence the outcome. Therefore, we evaluated the influence of dialytic modality on the rate of kidney transplantation and outcome in our single center. METHODS: Forty-two kidney transplants were carried among 1,573 dialysis patients from the years 1986 to 2004 in our center. Transposition rates from two modalities (HD and PD) and graft survival were compared. The incidence of acute rejection episode, complications after receiving transplantations, and coexisting diseases were also evaluated between the two modalities prior to transplantation. RESULT: The number of patients who received HD was larger than PD (HD 77.1%, PD 22.9%, respectively). Forty-two patients undergoing dialytic therapy received a living-donor kidney transplantation. Overall graft survival was 92% at 5 years and 75% at 10 years. Among these cases, dialytic modality prior to transplantation was 57.1% in HD, and 42.9% in PD. The transfer rate from PD to transplantation was significantly (p = 0.0036) higher (4.7%) than that of HD (1.9%). The reason for the high transfer rate of PD patients might be cooperation with their family and the provision of relevant information by nephrologists during PD. There were no differences between the two modalities prior to transplantation in the graft survival rate, incidence of acute rejection, and complications before and after transplantation. CONCLUSION: Difference in pretransplant dialysis modality did not affect the outcomes, however, the transfer rate from PD was significantly higher than from HD. Accordingly, PD is useful compared to HD as bridge therapy for kidney transplantation from the high feasibility of living-donor kidney transplantation.     

Renal replacement therapy options from an Indian perspective: dialysis versus transplantation

In developing countries such as India, the management of end-stage renal disease (ESRD) is largely guided by economic considerations. In the absence of health insurance plans, fewer than 10% of all patients receive renal replacement therapy (RRT). Hemodialysis (HD) is mainly a short-term measure to support ESRD patients prior to transplant. Infections are common in dialysis patients. The majority of patients starting HD die or are forced to abandon treatment because of cost constraints within the first 3 months. The cost of peritoneal dialysis (PD) is two times higher than that of HD, fewer than 2% of patients are started on PD. Among the three RRT options available, renal transplant is the preferred mode, as it is most cost-effective and provides a better quality of life. But due to financial constraints and nonavailability of organs, only about 5% of ESRD patients undergo transplant surgery. Though the removal of organs from brain-dead patients has been legalized, the concept of donation of organs from deceased donors has not received adequate social sanction. Only 2% of all transplants are performed from deceased donors. Due to limited access to RRT, the ideal approach should be to reduce the incidence of ESRD and attempt preventive measures. Preemptive transplant, reducing the duration of dialysis prior to transplant, use of immunosuppression for only up to 1 year, and availability of more deceased donor organs may be helpful to make RRT options within the reach of the common man.     

Survey on the current status of delivered informed consent for renal replacement therapy among patients with end-stage renal disease

We conducted a survey on the adequacy of delivered informed consent (IC) among patients with end-stage renal disease (ESRD) regarding the information provided on renal replacement therapies (RRT): Hemodialysis (HD), peritoneal dialysis (PD), and renal transplantation (RTx). A self-assessment style of questionnaire entitled "Informed consent for the selection of dialysis therapy modality" was prepared for evaluation, and the adequacy of IC was scored by 5 grades ranging from "excellent" to "bad". The questionnaire was sent to all the JSDT registered facilities (n=3484), and 480 centers replied (13.8%). Among these, 407 centers had patients introduced onto some form of RRT modality in the last 12 months. As to the adequacy of delivered IC for each modality, "excellent and good" status was reported as follows: 80.8% in HD, 49.8% in PD, and 32.5% in RTx, respectively. The major reason for "poor and bad" IC adequacy in PD and RTx, was "not available in the facility". By analyzing the facilities stratified by the clinical experiences of each modality in the past, poorly delivered IC for PD and RTx was revealed in centers lacking experience. Delivered information about RRT to ESRD patients may be biased in Japan. The findings of this study suggested that a lack of medical experience of the modality contributes to insufficient IC.     

Surgical Interventions for Renal Replacement Therapy from the View of Nephrologists

Summary BACKGROUND: The number of patients with end-stage renal disease (ESRD) is increasing worldwide at a rate of approximately 5 % per year. In Austria, 6049 patients were suffering from ESRD in the year 2001, an annual rate of 1093 patients. Higher age of patients and co-morbidities are forcing nephrologists to find the optimal renal replacement therapy (RRT) and access modality for the individual patient. METHODS: For patients with ESRD needing RRT, both nephrologist and surgeon should be consulted to ensure optimal management and treatment including vascular access surgery. Patients planned for peritoneal dialysis (PD) are treated with the cooperation of a visceral surgeon. A catheter is inserted into the pelvic area to enable solution exchange. In patients who are to undergo hemodialysis (HD), nephrologists have to decide whether the cardiac condition is suitable for surgical access creation such as fistula or graft. Otherwise alternative hemodialysis devices such as a central venous catheter (CVC), or subcutaneously implantable ports (Dialock^®), have to be discussed. Access function is routinely monitored during dialysis treatment, but still remains the weak component of extracorporeal RRT responsible for 40 % of hospitalization of HD patients. RESULTS: At the dialysis unit of the University Hospital of Graz, 107 patients were under RRT (70 HD and 37 PD), and 235 patients were hemodialyzed in private units in Graz in 2001. 81 ESRD patients were newly enrolled in the chronic HD program. 131 HD accesses were created in new HD patients and patients under treatment for chronic HD. 36 patients developed HD access complications and in these patients, 181 surgical and/or radiological interventions were performed. CONCLUSIONS: In 12 % of the HD patients in Graz, access problems occurred. These patients have a high frequency of surgical and radiological interventions. Access monitoring and measurement of recirculation may help to reduce the complication rate by 38 %. Before onset of RRT, patients need special management to ensure the best dialysis modality. ESRD patients who are suffering from cardiac diseases, diabetes mellitus, or bad peripheral vascular status need a multidisciplinary approach with nephrologists, cardiologists, surgeons and radiologists working together to find the optimal access for dialysis treatment.     

Management of the Dialysis Patient with Sickle Cell Disease

While patients with sickle cell disease currently constitute a very small minority of the US dialysis population (0.1%), there is anticipated growth of this group as the life expectancy of those with sickle cell disease (SCD) increases. SCD patients suffer a high burden of morbidity, which is enhanced by the presence of end‐stage renal disease (ESRD). In this review, we discuss the pathophysiology of SCD and the basic tenets of its management with focus on the dialysis patient with SCD. Anemia in dialysis patients with SCD is a unique challenge. The hemoglobin target in SCD dialysis patients with ESRD should not exceed 10 g/dl. SCD patients, and particularly those on dialysis, are likely to be poorly responsive to erythropoietin‐stimulating agent (ESA) therapy and might be at increased risk for vaso‐occlusive crisis (VOC) with ESA. Iron chelation and hydroyxurea therapy require special considerations and modifications in dialysis patients with SCD. There are theoretical advantages to both hemodialysis (HD) and peritoneal dialysis (PD) in SCD patients. With HD, there is a secure vascular access available for both standard and exchange blood transfusion in patients who need them. With PD, the absence of an acute rise in hematocrit with ultrafiltration (UF) might offer lower risk of VOC. During VOC, reduction in UF goals should be considered but administration of intravenous fluids should be reserved only for clear cases of volume depletion. Finally, renal transplantation appears to confer a survival advantage to dialysis in SCD patients and should be pursued when possible.     

Pretransplant dialysis modality and long-term patient and kidney allograft outcome: a 15-year retrospective single-centre cohort study

Among factors determining long-term kidney allograft outcome, pretransplant renal replacement therapy (RRT) is the most easily modifiable. Previous studies analysing RRT modality impact on patient and graft survival are conflicting. Studies on allograft function are scarce, lack sufficient size and follow-up. We retrospectively studied patient and allograft survival together with allograft function and its decline in 2277 allograft recipients during 2000–2014. Pretransplant RRT modality ≥60 days as grouped into “no RRT” (n = 136), “haemodialysis (HD)” (n = 1847), “peritoneal dialysis (PD)” (n = 159), and “HD + PD” (n = 135) was evaluated. Kaplan–Meier analysis demonstrated superior 5-/10-/15-year patient (93.0/81.8/73.1% vs. 86.2/71.6/49.8%), death-censored graft (90.8/85.4/71.5% vs. 84.4/75.2/63.2%), and 1-year rejection-free graft survival (73.8% vs. 63.8%) in PD versus HD patients. Adjusted Cox regression revealed 34.5% [1.5–56.5%] lower hazards of death, whereas death-censored graft loss was similar [HR = 0.707 (0.469–1.064)], and rejection was less frequent [HR = 0.700 (0.508–0.965)]. Allografts showed higher 1-/3-/5-year estimated glomerular filtration rate (eGFR) in “PD” versus “HD” groups. Living donation benefit for allograft function was most pronounced in groups “no RRT” and “PD”. Functional allograft decline (eGFR slope) was lowest for “PD”. Allograft recipients on pretransplant PD versus HD demonstrated superior all-cause patient and rejection-free graft survival along with better allograft function (eGFR).     

Advances in Peritoneal Dialysis: A Review

Peritoneal dialysis (PD) is a simple, “low‐tech” form of renal replacement therapy that is less expensive than conventional in‐center hemodialysis in many parts of the world. Despite the advantages associated with this modality, it has not been as embraced as it deserves to be in many countries, including the United States. This brief review will focus on recent interesting and germane publications related to therapy with PD, centering on three broad themes: (i) “biocompatible” PD solutions; (ii) encapsulating peritoneal sclerosis; and (iii) comparisons of survival between PD and conventional hemodialysis. Recent publications concerning biocompatible solutions are hampered by varying trial designs, confounding by indication, and solutions with different compositions. Perhaps the most robust result, a reduction in peritonitis, has not been a consistent finding across studies. The results are generally disappointing with respect to clinically relevant endpoints such as membrane function and patient survival. The rarity of encapsulating peritoneal sclerosis, still a vexing and worrying complication, hampers any systematic examination of pathogenesis and treatment. The establishment of registries may help to better understand this condition. In the absence of randomized, controlled trials of PD versus hemodialysis, survival analyses are fraught with enormous methodological and statistical pitfalls. Nevertheless, many investigators remain focused on small differences in survival between the two modalities; even more inappropriately, some clinicians use these imperfect data to guide their modality recommendations. Recent outcome studies suggest that the survival of patients on PD compared with conventional hemodialysis is astonishingly similar, and differences between early and late survival are more explainable by the circumstances around initiation than by the modality itself.     

Clinical Outcomes after Failed Renal Transplantation—Does Dialysis Modality Matter?

Patients returning to dialysis after graft loss (DAGL) are an increasing segment of the end-stage renal disease (ESRD) population. It is unclear whether patients with previous graft loss have equivalent or reduced survival from the time of restarting dialysis when compared with ESRD patients initiating dialysis for the first time. Moreover, the impact of dialysis modality on the survival of patients returning to DAGL is not known. Studies of patients with transplant graft failure returning to hemodialysis (HD) have suggested decreased survival when compared with transplant-naïve dialysis patients, yet some studies of patients with graft failure returning to peritoneal dialysis (PD) have demonstrated equivalent survival. Based on these data, it is unclear whether survival differences may exist between the dialysis modalities, and if they do, whether they can be attributed to either differences in patient characteristics or to factors related to the dialysis modalities. For patients starting back onto dialysis, in whom preservation of residual renal function is important, it is also unclear how immunosuppression reduction or transplant nephrectomy may affect survival. In this review, we will summarize the available literature on survival rates of patients returning to DAGL; compare and contrast survival after initiation of HD and PD and discuss what is known about the impact of transplant nephrectomy and the different approaches to immunosuppression reduction. Practical considerations will be discussed with a specific emphasis on patients treated by PD.     

Dialysis therapy for children with acute renal failure: survey results

We surveyed 123 pediatric nephrologists to investigate the current dialytic management of acute renal failure (ARF) in children. Data collected from 92 responding physicians revealed that hemodialysis (HD), peritoneal dialysis (PD), and continuous renal replacement therapy (CRRT) are currently used as the primary means of acute renal replacement therapy in a nearly equal percentage of centers. The preferential use of CRRT appears to be increasing, while PD usage is decreasing except for the youngest infants and those patients likely to develop end-stage renal disease (ESRD). Additional data correlating patient outcome to dialytic modality should be collected to compare the efficacy of the three techniques.     

The epidemiology of end-stage renal disease in the Baltic countries: an evolving picture.

INTRODUCTION: The epidemiology of end-stage renal disease (ESRD) and renal replacement therapy (RRT) is under continuous evolution all over the world. Of particular interest is the development of RRT in the countries of the former Soviet bloc which underwent great political and socio-economical changes in the last decade. We report here the epidemiological analysis of ESRD and RRT in the three Baltic countries: Lithuania, Estonia, Latvia. Subjects and methods. This epidemiological report is based on data from centre questionnaires which were collected from 1996 onwards, with a response rate of 98-99%. RESULTS: The prevalence/incidence of RRT patients in 1999 were 213/99.5 p.m.p. in Lithuania, 186/45.5 p.m.p. in Estonia and 172/55.8 p.m.p. in Latvia. Haemodialysis (HD) was the most common RRT modality in Lithuania (60% of prevalent patients), but not in Estonia (29%), while in Latvia it was nearly as common as renal transplantation (45 and 46%, respectively). Home HD was not performed. The proportion treated by peritoneal dialysis (PD) was very low in Lithuania (4% of RRT patients), while the percentage was higher in Latvia (9%) and Estonia (20.4%). The percentage of patients on RRT treated by renal transplantation was high throughout, representing the main modality of treatment in Estonia (50.5% of RRT prevalent patients, 94 p.m.p.) and in Latvia (46%, 79 p.m.p.) and being high in Lithuania (36%, 77 p.m.p.). The main renal diseases leading to ESRD were glomerulonephritis, pyelonephritis and diabetes. CONCLUSION: The epidemiology of RRT in the Baltic countries is undergoing rapid changes. Transplantation has reached an impressive level. A high percentage of RRT patients live with a functioning graft.     

Comparative studies of dialysis therapies should reflect real world decision-making

The incidence and prevalence of end-stage renal disease (ESRD) continues to rise. While transplantation is the preferred therapy for kidney failure, there is a shortage of donor organs, and the majority of patients will be treated with either peritoneal dialysis (PD) or hemodialysis (HD). Randomized controlled trials comparing patient outcomes on PD and HD are not likely to be successful, as individuals who are educated about their treatment options generally develop a strong preference for one therapy over the other and will not consent to randomization. As a result, prospective cohort studies are frequently the strongest study design available to compare outcomes between dialysis modalities. Previous studies have provided important insights into the relative merits of the 2 therapies. However, they have examined outcomes in relatively heterogeneous groups of ESRD patients and are generally not designed in a manner that mirrors clinical decision-making. We explore several key methodological challenges in the design of observational research in ESRD with a focus on minimizing selection bias and making studies more relevant to the practicing nephrologist. We emphasize that incident patients are preferred in most comparative studies of dialysis modalities. We argue that analyses comparing the outcomes of renal replacement therapy (RRT) modalities should include patients eligible for the therapies being compared and that the way that patients are assigned to treatment groups should reflect decision-making in clinical practice. Finally, the point at which baseline characteristics are measured and we begin tracking patients for the occurrence of outcomes should be chosen carefully.     

Survival and development of cardiovascular disease by modality of treatment in patients with end-stage renal disease.

Patients undergoing dialysis are at high risk for cardiovascular disease (CVD). The aim of this study was to evaluate the influence of hemodialysis (HD) versus peritoneal dialysis (PD) on survival and the risk of developing de novo CVD. Of the 4191 patients with end-stage renal disease (ESRD) who started renal replacement treatment (RRT) in Lombardy between 1994 and 1997, 4064 (who were on dialysis 30 d after the start of RRT) were considered for survival analysis: 2772 were on HD (mean age 60.9 yr; 21.2% diabetic) and 1292 on PD (mean age 63.6 yr; 16% diabetic). The 3120 patients who were free of CVD at the start of RRT were included in the analysis of the risk of developing de novo CVD. HD and PD were compared by use of a Cox-regression proportional hazard model, stratified by diabetic status; the explanatory covariates were age and gender. The death rate was 13.3 per 100 patient-years (13.0 on HD and 13.9 on PD); 197 (6.3%) of the 3120 patients included in the CVD analysis developed de novo CVD (128 on HD and 69 on PD). After adjustment for age, gender, and established CVD and stratification by diabetic status, there was no significant between-treatment difference in 4-yr survival (relative risk [RR], 0.91; 95% confidence interval [CI], 0.79 to 1.06). The risk of de novo CVD did not differ significantly by treatment modality (RR, 1.06; 95% CI, 0.79 to 1.43). The risk of mortality and de novo CVD for new patients with ESRD assigned to HD or PD was similar in Lombardy in the period 1994 through 1997.     

End stage renal disease in Brunei Darussalam – report from the first Brunei Dialysis Transplant Registry (BDTR)

Abstract

The Brunei Dialysis and Transplant Registry (BDTR) was established in 2011 to collect data from patients undergoing renal replacement therapy (RRT) in Brunei Darussalam. The chief aims of the registry are to obtain general demographic data for RRT patients and to determine disease burden attributable to End Stage Renal Disease (ESRD). The registry population comprises of all ESRD patients treated in Brunei Darussalam. Data domains include general demographic data, medical history, ESRD etiological causes, laboratory investigations, dialysis treatment and outcomes. There were 545 prevalent RRT patients in Brunei at the end of 2011. The incidence and prevalence of ESRD were 265 and 1250 per million population. Hemodialysis (HD), Peritoneal Dialysis (PD) and Transplant comprised of 83%, 11% and 6% of the RRT population, respectively. Diabetes mellitus accounted for 57% of all new incident cases. The mean serum hemoglobin, phosphate, calcium and iPTH were 11.0?±?1.6?g/dL, 1.9?±?0.5?mmol/L, 2.3?±?0.2?mmol/L and 202.5?±?323.4?ng/mL. Dialysis adequacy for HD and PD were 65.1 (urea reduction ratio) and 2.0?±?0.3 (Kt/v). 71 % of all prevalent HD had functioning AV fistulae and the peritonitis incidence was one in 24.5 patient-month/episode. The first BDTR has identified some deficiencies in the renal services in Brunei. However, it signals an important milestone for the establishment of benchmarked renal practice in the country. We hoped to maintain and improve our registry for years to come and will strive to align our standards to acceptable international practice.     

Pediatric Kidney Transplantation in the Developing World: Challenges and Solutions

The prevalence of pediatric RRT and transplantation are low in developing countries, 6–12 and <1 to 5 per million child population (pmcp), respectively. This is due to low GDP/capita of <$10 000, government expenditure on health of <2.6–9% of GDP and paucity of facilities. The reported incidence of pediatric CKD and ESRD is <1.0–8 and 3.4–35 pmcp, respectively. RRT and transplantation are offered mostly in private centers in cities where HD costs $20–100/session and transplants $10 000–20 000. High costs and long distance to centers results in treatment refusal in up to 35% of the cases. In this backdrop 75–85% of children with ESRD are disfranchised from RRT and transplantation. Our center initiated an integrated dialysis–transplant program funded by a community‐government partnership where RRT and transplantation was provided “free of cost” with life long follow‐up and medication. Access to free RRT at doorsteps and transplantation lead to societal acceptance of transplantation as the therapy of choice for ESRD. This enabled us to perform 475 pediatric transplants in 25 years with 1‐ and 5‐year graft survival of 96% and 81%, respectively. Our model shows that pediatric transplantation is possible in developing countries when freely available and accessible to all who need it in the public sector.     

Malnutrition–Inflammation–Atherosclerosis (MIA) Syndrome Components in Hemodialysis and Peritoneal Dialysis Patients

Background. Malnutrition, inflammation, and atherosclerosis (MIA syndrome) are common in end-stage renal disease (ESRD) patients. Each component of MIA syndrome is the predictor of outcomes in ESRD patients. In this cross-sectional study, we aimed to compare both dialysis modalities for MIA syndrome components. Material and Methods. Thirty hemodialysis (HD) (mean age 44 ± 11 years, 14 male and 16 female, mean time on dialysis: 31.0 ± 19.0 months) and 30 continuous ambulatory peritoneal dialysis (CAPD) patients (41 ± 9 years, 12 male and 18 female, mean time on dialysis: 25.5 ± 21.5 months) were included. In order to determine malnutrition in ESRD patients, serum albumin level and anthropometric measurements were used. For inflammation, serum C-reactive protein level, erythrocyte sedimentation rate, and fibrinogen levels were measured. Mean-carotid artery intima media thickness (m-CIMT), presence of carotid plaque and serum homocysteine level were used to determine atherosclerosis. Results. Five CAPD patients (16%) and one HD patient (3%) was hypoalbuminemic. HD and CAPD groups were similar for inflammation. Mean-CIMT and serum homocysteine level were higher in HD patients than CAPD patients. There was a positive correlation between homocysteine and m-CIMT. Conclusion. Before choosing renal replacement therapy, malnutrition, inflammation, and atherosclerosis parameters must be investigated in ESRD patients. Hemodialysis seems to be more advantageous for malnutrition components than CAPD. Both dialysis modalities seem to be similar for inflammation, and CAPD modality has superiority for atherosclerosis. Before choosing the type of renal replacement therapy, assessment of MIA syndrome components could be useful for individualization of the decision on which dialytic modality is appropriate in ESRD patients.     

We Offer Renal Replacement Therapy to Patients Who Are Not Benefitted by It

Nephrologists offer renal replacement therapy (RRT) to patients who are unlikely to benefit in part because of our discomfort discussing goals of care in the setting of an uncertain prognosis for a given individual. Permanent neurological impairment, terminal illness (life expectancy <6 months), medical conditions precluding the safe delivery of dialysis, elderly patients with poor prognosis, and those who begin “early” RRT are categories of patients for whom dialysis may not be beneficial. Successful use of time‐limited trials of dialysis may reduce the number of patients who are started on RRT without significant benefit. However, clear achievable milestones and goals need to be incorporated into plans for time‐limited trials to ensure that continuing RRT beyond the trial period is appropriate. The lack of information on outcomes and symptom management using a “palliative approach” to dialysis suggests this should not be a clinical option until additional study is done and efficacy data available. Clinical practice guidelines are available to assist nephrologists in the appropriate withholding of RRT.     

Time trends in initiation and dose of dialysis in end-stage renal disease patients in The Netherlands.

BACKGROUND: The guidelines published by the NKF-Dialysis Outcomes Quality Initiative (DOQI) in 1997 advocate an earlier start of dialysis in ESRD patients and a higher dialysis dose than usual. We studied the possible influence of the increasing emphasis on adequate dialysis on the management of ESRD patients in The Netherlands in 1993-2000. METHODS: The NECOSAD study on the adequacy of dialysis started in 1993. This prospective multi-centre study included ESRD patients older than 18 years who started HD or PD as the first RRT. We analysed the distribution of age, gender, primary renal disease and co-morbidity, the mean residual renal function and the mean dialysis-Kt/V(urea) at 3 months in 1569 consecutive patients by calendar year of initiation dialysis. RESULTS: Age, gender, primary renal disease and number of co-morbid conditions at the start of dialysis remained stable over time between 1993 and 2000. The mean renal Kt/V(urea) at 3 months increased from 0.5 in 1993 to 0.8 per week in 2000 (P<0.01). An upward trend remained after adjustment for patient characteristics and dialysis centre. The total Kt/V(urea) at 3 months increased from 3.3 in 1993 to 3.7 per week in 2000 in HD (P<0.01) and from 2.0 in 1993 to 2.3 per week in 1999 in PD patients (P<0.01). An upward trend in the dialysis-Kt/V(urea) was found after adjustment for renal Kt/V(urea) (HD: +0.3 per week, P=0.06; PD, +0.2 per week, P<0.05). CONCLUSIONS: These results indicate a tendency towards earlier introduction of RRT and higher doses of dialysis in The Netherlands. Possible effects of this development on mortality, morbidity, quality of life and the balance between costs and benefits need further investigation.     

Shared Decision Making Increases Living Kidney Transplantation and Peritoneal Dialysis

BackgroundHospital accreditation in Taiwan encourages greater use of shared decision making (SDM) in health care. This study aimed to explore the distribution change of treatment modalities for renal replacement therapy (RRT) before and after the use of SDM in newly diagnosed end-stage renal disease (ESRD) patients.MethodsThe processes of SDM for RRT were designed with Internet-based patient educational program and smart system. The project of SDM was reviewed by departmental consensus meeting and continuously executed since January 2017. Patients received long-term RRT between January 2016 and December 2017 were enrolled.ResultsIn 2017, 310 patients (187 male, average 63.9 years old) received long-term RRT. Of them, 220 (71%) patients completed SDM for RRT. Sixty-six patients received peritoneal dialysis (PD), 67 patients entered the evaluation of living related kidney transplantation (KT) program, while 18 patients finally received operation for living KT. Compared to 2016, execution of SDM for RRT was associated with drastically increase of the number of living KT (38.5%) and PD (112.9%) after the implementation of SDM for RRT in 2017. The number of preemptive living KT was also increased from 1 patient to 5 patients. Moreover, 91.3% patients were satisfied with the process of SDM for RRT.ConclusionOur findings suggest that the implementation of SDM before patients entering long term RRT lead to more ESRD patients receiving living KT and entering PD therapy. The increasing trend of living KT could be reasonably expected if SDM for RRT could be carried out nationwide.     

Health-related quality of life in different stages of renal failure

Measures of health-related quality of life (HRQoL) have a significant predictive value on patient survival and hospitalizations, especially in patients with chronic kidney disease (CKD). In this review, some of the major studies performed in patients with different stages of renal failure are presented. The most used instrument for measuring HRQoL is the Short form health survey questionnaire (SF-36). Patients with predialysis CKD had higher SF-36 scores than a large cohort of hemodialysis (HD) or peritoneal dialysis (PD) patients, but lower scores than those reported for the adult population. Kidney transplantation offers better HRQoL than dialysis. Hemoglobin level predicted both physical and mental domain scores of the SF-36. HRQoL of HD and PD patients were compared in only a few studies, mostly because these studies are difficult to interpret. PD patients generally have lower comorbidity scores at the onset of end-stage renal disease (ESRD), independent of other factors influencing modality selection. Comorbid medical conditions are common in patients with ESRD, and are an important contributing factor to clinical outcomes and quality of life. Depression occurs in about 20-30% of dialysis patients. This is important because of the negative impact depression has on quality of life, but also because depression is now established as a factor that can significantly affect morbidity and mortality in ESRD patients. Sexual life satisfaction showed marked deterioration in all age groups. Patients aged over 65 scored significantly better than younger patients on dialysis stress scales, and were generally more satisfied with life. Longitudinal studies are needed to define periods at risk for decline in HRQoL during progression of CKD.