CHAPTER 12. Peritoneal Dialysis

Transcription

1 23rd Report of the PERITONEAL DIALYSIS CHAPTER 12 Peritoneal Dialysis Sunita Bavanandan Anita Bhajan Manocha Lily Mushahar Mohamad Zaimi Bin Abdul Wahab

2 PERITONEAL DIALYSIS 23rd Report of the SECTION 12.1: Modali es and Prescrip on of PD (Tables ) In 2015, there are 4315 pa ents on peritoneal dialysis (PD) in Malaysia this represents a growth of 16.5 from the preceding year and 178 over the last decade. The bulk of PD therapy remains in the form of CAPD (82.9) with no growth in the propor on on APD (13.2) and a declining number on DAPD (3.9 versus 5.2) (Table ). It would be interes ng to see if this trend is related to increasing use of Icodextrin in long overnight dwells but that data is not presently captured. Table : Peritoneal dialysis regimes, PD regime n n n n n Standard CAPD DAPD Automated PD/ CCPD Total PD regime n n n n n Standard CAPD DAPD Automated PD/ CCPD Total In 2015, 65.5 of pa ents were on the Baxter disconnect system and 34 on the Fresenius disconnect system (Table ). The majority of pa ents on CAPD (90.3) are using 4 exchanges a day. Fewer pa ents compared to previous years are performing 5 exchanges a day. This may reflect a lower threshold to convert pa ents requiring be er clearances to haemodialysis (Table a). The majority (83) of pa ents on APD use 10L total volume exchanges daily but there are 6.2 using 8L exchanges and 8.1 using >10L exchanges daily (Table bi). For CAPD, 87.6 of pa ents in 2015 are using 8L total volume exchanges, while 9 use 10L exchanges daily. Table : CAPD connectology, CAPD connectology n n n n n CAPD Baxter disconnect Fresenius disconnect Others Unknown APD Baxter disconnect Fresenius disconnect Others Unknown

3 23rd Report of the PERITONEAL DIALYSIS Table : CAPD connectology, ( cont) CAPD connectology n n n n n CAPD Baxter disconnect Fresenius disconnect Others Unknown APD Baxter disconnect Fresenius disconnect Others Unknown Table a: CAPD Number of Exchanges per day, Number of exchanges/ day n n n n n Unknown Total Number of exchanges/ day n n n n n Unknown Total Table bi: APD total dwell volumes per day, Total dwell volumes/ day n n n n n Unknown Total

4 PERITONEAL DIALYSIS 23rd Report of the Table bi: APD total dwell volumes per day, ( cont) Total dwell volumes/ day n n n n n Unknown Total Table bii: CAPD total dwell volumes per day, Total dwell volumes/ day n n n n n Unknown Total Total dwell volumes/ day n n n n n Unknown Total In 2015, the number of pa ents doing self-care CAPD was 63 whereas this propor on was only 32 in APD. This indicates that the requirement for assistance (coupled with access to?nancing) is the main determinants for the choice of APD rather than correla on with membrane status. Table : Assistance to Perform PD, PD regime/assistance n n n n n CAPD Self-care Par al self-care Completely assisted Unknown Automated PD Self-care Par al self-care Completely assisted Unknown

5 23rd Report of the PERITONEAL DIALYSIS Table : Assistance to Perform PD, ( cont) PD regime/assistance n n n n n CAPD Self-care Par al self-care Completely assisted Unknown Automated PD Self-care Par al self-care Completely assisted Unknown Figure (a): Assistance to Perform CAPD, Figure (b): Assistance to Perform APD, Self-care completely assisted Partial Self-care Unknown Self-care completely assisted Partial Self-care Unknown Percent () Percent () CAPD APD SECTION 12.2: ACHIEVEMENT OF SOLUTE CLEARANCE AND PERITONEAL TRANSPORT The percentage of pa ents achieving target solute clearance of 1.7 per week has been declining over the last decade (Table ). This trend may be due to a change in the recommended target Kt/V on PD adequacy in 2007 and highlights the need to actually target a higher Kt/V to achieve the minimum requirement in solute clearance. There is a 1.6-fold inter-centre varia on in the propor on of pa ents achieving the delivered Kt/V in 2015 (55 in 5th percen le and 89 in 95th percen le). This wide inter-centre varia on has been present every year (Table ). The majority of incident PD pa ents have either low average or high average membrane transport status (Table ). However, there was a shi to high average and high transport status over me (Table ). Table and Figure shows the decline in residual renal volume (RRV) over me although up to 50 of PD pa ents have urine output above 400 mls un l 4 years on PD. 171

6 PERITONEAL DIALYSIS 23rd Report of the Table : Distribu on of delivered Kt/V, PD pa ents Year Number of pa ents Mean SD Median LQ UQ pa ents 1.7 per week Figure : Cumula ve distribu on of delivered Kt/V, PD pa ents Figure : Varia on in propor on of pa ents with Kt/V 1.7 per week among PD centres with KT/V >=1.7 per week (lower 95 CI, upper 95 CI) 80 Cumulative distribution patients KT/V Centre Table : Varia on in propor on of pa ents with Kt/V 1.7 per week among PD centres, Year Number of centre Min 5 th Cen le Median LQ UQ 95 th Cen le Max 172

7 23rd Report of the PERITONEAL DIALYSIS Table : Peritoneal transport status by PET D/P crea nine at 4 hours, new PD pa ents Year n n n n n Low Low average High average High Total Year n n n n n Low Low average High average High Total Table : Peritoneal Transport Status (PET) with dialysis vintage Dura on (Years) <1 1-<2 2-<3 3-<4 4-<5 n n n n n Low Low average High average High Total Dura on (Years) 5-<6 6-<7 7-<8 8-<9 9-<10 10 or more n n n n n n Low Low average High average High Total Table : Residual Urine Volume Dura on (Years) <1 1-<2 2-<4 4 or more n n n n <100 ml <400 ml <800 ml <1000 ml >=1000 ml Total

8 PERITONEAL DIALYSIS 23rd Report of the Figure : Residual Urine Volume in prevalent PD pa ents (2015) 100 <100 mls 100-<400 mls 400-<800 mls 800-<1000 mls >=1000 mls 80 Percent () <1 1-<2 2-<4 >=4 Duration(Years) SECTION 12.3: TECHNIQUE SURVIVAL ON PD Table and Figure a & b show pa ent technique survival by era. Technique survival was be er in the first 4 years in the recent era () compared to when censored for death and transplant. In, technique survival was 93, 79 and 72 at 1, 3 and 4 years respec vely. Younger age group (age <14 years) had be er technique survival in the first 5 years (censored for death and transplant) compared to older age group (Table & Figure b) but a er 5 years on treatment, age 65 years had be er technique survival compared to younger age group (Table & Figure b). Tables and Figures (a) & (b) show those of female gender consistently had be er technique survival than their male counterparts. Table (a): Unadjusted technique survival by era and (uncensored for death and transplant) Era Interval (month) n Survival SE n Survival SE

9 23rd Report of the Figure a: Unadjusted technique survival by era and (uncensored for death and transplant) PERITONEAL DIALYSIS Figure (b): Unadjusted technique survival by era and (censored for death and transplant) 1.00 Kaplan-Meier survival estimates, by Era 1.00 Kaplan-Meier survival estimates, by Era Cumulative survival Year Year Cumulative survival Year Year Duration in months Duration in months Table (b): Unadjusted technique survival by era and (censored for death and transplant) Era Interval (month) n Survival SE n Survival SE Table (a): Unadjusted technique survival by age (uncensored for death and transplant) Age group (years) <= Interval (month) n Survival SE n Survival SE n Survival SE n Survival SE 175

10 PERITONEAL DIALYSIS 23rd Report of the Table (a): Unadjusted technique survival by age (uncensored for death and transplant) ( cont) Age group (years) Interval (month) n >=65 Survival SE n Survival SE n Survival SE Figure (a): Unadjusted technique survival by age (uncensored for death and transplant) Kaplan-Meier survival estimates, by Age Figure (b): Unadjusted technique survival by age (censored for death and transplant) Kaplan-Meier survival estimates, by Age Age 1-14 Cumulative survival Age Age Age Age 1-14 Age>=65 Age Age Cumulative survival Age Age Age Age>=65 Age Age Duration in months Duration in months 176

11 23rd Report of the PERITONEAL DIALYSIS Table (b): Unadjusted technique survival by age (censored for death and transplant) Age group (years) Interval (month) n <= Survival SE n Survival SE n Survival SE n Survival Age group (years) Interval (month) n >=65 Survival SE n Survival SE n Survival SE SE 177

12 PERITONEAL DIALYSIS 23rd Report of the Table (a): Unadjusted technique survival by gender (uncensored for death and transplant) Gender Interval (months) Male Female n survival SE n survival SE Figure (a): Unadjusted technique survival by gender (uncensored for death and transplant) Figure (b): Unadjusted technique survival by gender (censored for death and transplant) 1.00 Kaplan-Meier survival estimates, by sex 1.00 Kaplan-Meier survival estimates, by sex Cumulative survival Male Female Cumulative survival Male Female Duration in months Duration in months Table (b): Unadjusted technique survival by gender (censored for death and transplant) Gender Interval Male Female (months) n survival SE n survival SE

13 23rd Report of the PERITONEAL DIALYSIS Table & Figure (a) show diabe c status is ini ally associated with worse technique survival compared to non-diabe c (uncensored for death and transplant). However, when censored for death and transplant, technique survival was not different between diabe c vs non-diabe c status in the first 5 years on treatment. A er 5 years on treatment, technique survival was actually be er for pa ents with diabetes than those without (Table & Figure (b) ). Table (a): Unadjusted technique survival by diabetes status (uncensored for death and transplant), Diabetes status Interval (month ) Non-diabe c Diabe c n survival SE n survival SE Figure (a): Unadjusted technique survival by Diabetes status (uncensored for death and transplant) Kaplan-Meier survival estimates, by Diabetes Figure (b): Unadjusted technique survival by diabetes status (censored for death and transplant) Kaplan-Meier survival estimates, by Diabetes Cumulative survival Non-diabetic Cumulative survival Diabetic Non-diabetic Diabetic Duration in months Duration in months 179

14 PERITONEAL DIALYSIS 23rd Report of the Table (b): Unadjusted technique survival by diabetes status (censored for death and transplant) Diabetes status Non-diabe c Diabe c Interval (month ) n survival SE n survival SE There was no difference in technique survival between Kt/v >2.0 and Kt/V > Pa ents with Kt/V <1.7 had the worst technique survival (Table & Figure ). Table : Unadjusted technique survival by Kt/V, Kt/V Interval (months ) n < >2.0 Survival SE n Survival SE n Survival SE 180

15 23rd Report of the PERITONEAL DIALYSIS Figure : Unadjusted technique survival by Kt/V, Kaplan-Meier survival estimates, by KTV Cumulative survival Kt/V Kt/V <1.7 Kt/V > Duration in months Table shows the hazard ra o for change of dialysis modality. Factors significantly influencing change of dialysis modality were peritoni s, male gender, BMI >=25, serum albumin <30 g/dl, Hb <10.0gm/dl, serum phosphate <0.8mmol/l and Kt/V <1.7. Table : Adjusted hazard ra o for change of dialysis modality, Factors n Hazard ra o 95 CI p value Age (years) Age 1-14 (ref*) Age (0.89, 1.79) Age (0.70, 1.44) Age (0.65, 1.33) Age (0.59, 1.20) Age (0.65, 1.30) Age >= (0.61, 1.29) Peritoni s No (ref*) Yes (6.68, 8.55) <0.001 Diabetes Mellitus Non-diabe c (ref*) Diabe c (0.89, 1.19) Gender Male (ref*) Female (0.68, 0.89) <0.001 Cardiovascular Disease No CVD (ref*) CVD (0.74, 1.09) BMI < (0.84, 1.34) <25 (ref*) >= (1.27, 1.66) <

16 PERITONEAL DIALYSIS 23rd Report of the Table : Adjusted hazard ra o for change of dialysis modality, ( cont) Factors n Hazard ra o 95 CI p value Serum Albumin < (1.04, 1.44) < (0.91, 1.20) <45 (ref*) >= (0.41, 1.69) Serum cholesterol (mmol/l) < (0.84, 1.50) < (0.61, 0.85) < < (0.79, 1.14) >=6.2 (ref*) Diastolic BP < (0.77, 1.23) < (0.87, 1.18) <90 (ref*) < (1.01, 1.44) >= (0.82, 1.75) Hemoglobin (g/dl) < (1.22, 1.59) < <12 (ref*) >= (0.78, 1.27) Serum calcium (mmol/l) < (0.92, 1.22) <=2.37 (ref*) > (0.86, 1.22) Calcium Phosphate product < (0.98, 1.40) <4.5 (ref*) < (0.59, 0.98) >= (0.66, 1.41) Serum Phosphate (mmol/l) < (1.89, 6.18) < <1.3 (ref*) < (0.73, 1.03) < (0.67, 1.15) >= (0.82, 1.76) Kt/V < (1.01, 1.41) (ref*) <= (0.90, 1.20) Assisted PD Selfcare (ref*) Assisted (0.79, 1.05)

17 23rd Report of the PERITONEAL DIALYSIS Table (a) shows the reasons for PD drop out. The percentage of death (60) as a cause for PD drop-out in 2015 was compara vely low to prior 8 years. A er excluding death, peritoni s persisted as the commonest cause of technique failure over the last decade. Peritoni s contributed to 20 of PD drop-out in year 2015, followed by membrane failure (6). Table (b) shows the PD drop-out rate with me on treatment. A propor on of PD drop-out occurred before 12 months of treatment (30), while 70 occurred a er 12 months on treatment (Table b). The dura on of me spent on PD by prevalent pa ents is shown in Table A total of 709 pa ents (8.4) s ll remain on PD a er 5 years on treatment. Table (a): Reasons for drop-out from PD program, Year n n n n n n Death Transplant Peritoni s Catheter related infec on Membrane failure Technical problem Pa ent preference Others Unknown Total Year n n n n Death Transplant Peritoni s Catheter related infec on Membrane failure Technical problem Pa ent preference Others Unknown Total

18 PERITONEAL DIALYSIS 23rd Report of the Figure (a): Reasons for drop-out from PD program, Death Peritonitis Membrane failure Patient preference Unknown Transplant Catheter related infection Technical problem Others Percent () Table (b): Drop-out rate from PD program with me on treatment, Year n n n n n n < 3 months <6 months <12 months >=12 months Total Year n n n n < 3 months <6 months <12 months >=12 months Total

19 23rd Report of the PERITONEAL DIALYSIS Table : Time on PD (Prevalent PD pa ents 31 Dec 2015) 1 st Treatment (n=8459) 1 st Treatment (n=8459) Months 0-< Months SECTION 12.4: PERITONITIS The median peritoni s rate was 1 in 39.9 pa ent-months in 2015, compared to 1 in 42.9 pa entmonths in the preceding year (Table ).Inter-centre varia on remains wide from 1 episode in 19.8 pa ent-months to 1 in 96 pa ents-months (0.6 to 0.125) episodes per year at risk) in adults. Gram-posi ve organisms accounted for 35.3 of peritoni s with Staphylococcus coagulase nega ve (CoNS) as the predominant gram-posi ve organism (13.4). E. coli remained the commonest gramnega ve pathogen accoun ng for 28.4 of gram-nega ve infec ons. The fungal peritoni s rate remained rela vely unchanged at 3.9 and there was only 0.2 of mycobacterium peritoni s. The culture nega ve rate unfortunately remained high at 25.9 as compared to the ISPD target of less than 20 (Table & Figure ). For outcomes of peritoni s, it was clear that gram posi ve infec ons had be er outcomes (Table and Figure a & b). There was complete resolu on in 77.5 cases overall in the era (Table & Figure b) Gram nega ve peritoni s had higher rates of catheter removal (17.7 ) compared to gram posi ve peritoni s (10.2). The incidence of death was also higher in gram nega ve peritoni s compared to gram posi ve peritoni s, i.e versus 12.2 respec vely. Among gram nega ve infec ons, Pseudomonas and Acinetobacter have the highest incidence of deaths (30). Death rates from fungal and mycobacterial peritoni s were highest at 45 and 52 respec vely (Table & Figure b). When comparing the last 2 eras of PD i.e. and, the total mortality rate has decreased from 29.6 to Resolu on of peritoni s has improved from 53 to 58. These improvements are perhaps due to be er and earlier recogni on of peritoni s both by pa ent and staff. Catheter removal rates were similar in both eras. Total mortality rates con nue to decrease in fungal and mycobacterium peritoni s and can be explained by the ins tu on of a more aggressive approach to remove catheters. In mul variate analysis (Table ) lower income levels, age > 55 years and assistance with PD therapy appeared to contribute to an increased peritoni s risk. Diabetes was not associated with an increased risk of peritoni s. 185

20 PERITONEAL DIALYSIS 23rd Report of the Table : Varia on of peritoni s rate (pt-month/epi) among PD centres, Year Number of centres Min 5 th Cen le LQ Median UQ 95 th Cen le Max Figure (i): Varia on in peritoni s rate among adult PD centres, 2015 Figure (ii): Varia on in peritoni s rate among paediatric PD centres,

21 23rd Report of the PERITONEAL DIALYSIS Table : Causa ve organism in PD peritoni s, (A) Gram Posi ves n n n n n n n Staph. aureus Staph Coagulase Neg Strep Others (B) Gram Nega ves Pseudomonas Acinetobacter Klebsiella Enterobacter E.Coli Others (C) Polymicrobial (D) Others Fungal Mycobacterium Others (E) No growth Total (A) Gram Posi ves n n n Staph. aureus Staph Coagulase Neg Strep Others (B) Gram Nega ves Pseudomonas Acinetobacter Klebsiella Enterobacter E.Coli Others (C) Polymicrobial (D) Others Fungal Mycobacterium Others (E) No growth Total

22 PERITONEAL DIALYSIS 23rd Report of the Figure Causa ve organism in PD peritoni s, Frequency Staph. Aureus Other Gram positive E.Coli Fungal Culture Negative Staph Coagulase Neg. Pseudomonas Polymicrobial Mycobacterium Table (a): Outcome of peritoni s by causa ve organism, (A) Gram Posi ves Outcome Resolved Not resolved, catheter removed Death Total n n n n Staph. Aureus Staph Coagulase Neg Strep Others (B) Gram Nega ves Pseudomonas Acinetobacter Klebsiella Enterobacter E.Coli Others (C) Polymicrobial (D) Others Fungal Mycobacterium Others (E) No growth

23 23rd Report of the PERITONEAL DIALYSIS Table (b): Outcome of peritoni s by causa ve organism, (A) Gram Posi ves Outcome Resolved Not resolved, catheter removed Death Total n n n n Staph. Aureus Staph Coagulase Neg Strep Others (B) Gram Nega ves Pseudomonas Acinetobacter Klebsiella Enterobacter E.Coli Others (C) Polymicrobial (D) Others Fungal Mycobacterium Others (E) No growth Figure (a): Outcome of peritoni s by causave organism, 100 Resolved Not resolved, catheter removed Death Figure (b): Outcome of peritoni s by causa ve organism, 100 Resolved Not resolved, catheter removed Death Percent ( ) P ercent ( ) Staph. Aureus Staph Coagulase Neg. Strep Others Pseudomonas Acinetobacter Klebsiella Enterobacter E.Coli Others Polymicrobial Fungal Mycobacterium Others No growth 0 Staph. Aureus Staph Coagulase Neg. Strep Others Pseudomonas Acinetobacter Klebsiella Enterobacter E.Coli Others Polymicrobial Fungal Mycobacterium Others No growth 189

24 PERITONEAL DIALYSIS 23rd Report of the Figure (c): Outcome of peritoni s by causa ve organism by era, & Resolved Not resolved, catheter removed Death 100 Percent () Staph. Aureus Staph Coagulase Neg. Strep Others Pseudomonas Acinetobacter Klebsiella Enterobacter E.Coli Others Polymicrobial Fungal Mycobacterium Others No growth Outcome of peritonitis by causative organism by era Table : Risk factors influencing peritoni s rate, Factors n Risk Ra o 95 CI P value Age (years) <= (0.74, 1.08) (0.80, 1.09) (ref*) (0.90, 1.18) (0.92, 1.19) (1.06, 1.36) >= (1.09, 1.43) Gender Male (ref*) Female (0.97, 1.10) Diabetes No (ref*) Yes (0.89, 1.02) Income <RM 1000 (ref*) RM (0.76, 0.86) <0.001 RM (0.60, 0.74) <0.001 RM (0.48, 0.98) >=RM (0.27, 1.21) Educa on Nil (0.96, 1.22) 0.21 Primary (0.94, 1.09) Secondary (ref*) Ter ary (0.85, 1.07) Assistance to perform CAPD Self care (ref*) Par ally assisted (1.02, 1.22) Completely assisted (1.06, 1.25)