Chapter 12 PERITONEAL DIALYSIS

Transcription

1 Chapter 12 PERITONEAL DIALYSIS B. Sunita A/P V. Bavanandan Anita Bhajan Manocha Lily Binti Mushahar Mohamad Zaimi Bin Abdul Wahab Sudhaharan Sivathasan

2 PERITONEAL DIALYSIS 22nd Report of the SECTION 12.1: MODALITIES AND PRESCRIPTION OF PD (TABLES ) The number of patients treated with Peritoneal Dialysis (PD) in Malaysia has grown by approximately 2.7 times over the last decade where the prevalence of PD patients as of 31st December has increased from 1174 in the year 2005 to 3149 patients for the year PD therapy overall comprises 9.4 of the total number of dialysis patients (Table (b)). The bulk of PD therapy (81.3) remains in the form of Continuous Ambulatory Peritoneal Dialysis (CAPD). Automated Peritoneal Dialysis (APD) utilization has increased from a mere 3.6 in 2005 to the present level of However, in the last five years the growth of APD has ceased (Table ). There has been an increased utilization of the Fresenius Medical Care (FMC) system, with the ratio of FMC to Baxter approaching 1:3 by 2014 (Table ). The majority of patients on CAPD (91.5) are using 4 exchanges per day, while 81.8 of those on APD are using total dwell volumes of 10L per day (Tables12.1.3a and Table b). In CAPD, the majority of patients (65) practice self care but in APD, the largest proportion (66) are either completely or partially assisted. In terms of age distribution, it is clear PD is the preferred modality in the paediatric age groups where for ages 1-14 years, 78 of new patients start PD, for those aged 15 to 24 years it is approximately one-quarter and in the young working age group of years, one-fifth choose PD (Tables12.1.5(a) and (b)). There are no significant gender differences in choice of PD therapy (Tables (a) and (b)). Table : Peritoneal dialysis regimes, PD regime n n n N n Standard CAPD DAPD AutomatedPD/ CCPD TOTAL PD regime n n n N n Standard CAPD DAPD AutomatedPD/ CCPD TOTAL

3 22nd Report of the PERITONEAL DIALYSIS Table : CAPD connectology, CAPD connectology n n n N n Baxter disconnect Fresenius disconnect Others TOTAL CAPD connectology n n n N n Baxter disconnect Fresenius disconnect Others TOTAL Table a: CAPD Number of Exchanges per day, Number of exchanges/ day n n n n n N TOTAL Number of exchanges/ day n n n N n TOTAL Table b: APD dwell volumes per day, Dwell volumes/ day n n n N n TOTAL Dwell volumes/ day n n n N n TOTAL

4 PERITONEAL DIALYSIS 22nd Report of the Table : Assistance to Perform PD, PD regime/assistance n n n N n CAPD Self care Partial self care Completely assisted Unknown Automated PD Self care Partial self care Completely assisted Unknown PD regime/assistance n n n N n CAPD Self care Partial self care Completely assisted Unknown Automated PD Self care Partial self care Completely assisted Unknown Figure (a): Assistance to Perform CAPD, Self-care completely assisted Partial Self-care Unknown Figure (b): Assistance to Perform APD, Self-care completely assisted Partial Self-care Unknown Percent () Percent () CAPD APD 160

5 22nd Report of the PERITONEAL DIALYSIS Table (a): PD Treatment Rate by Age Group, per million age group population Age groups (years) Table (b): Percentage Age Distributionof PD Patients Year n n n n N n n n n N New Dialysis patients years years years years years years >=65 years Dialysing at 31 st December years years years years years years >=65 years Where = PD / HD+PD The numbers in table for incident and prevalent pts are reversed - pl correct Table (a): PD Treatment Rate by Gender, per million male or female population Gender Male Female

6 PERITONEAL DIALYSIS 22nd Report of the Table (b): Gender Distributionof PD Patients n n n n n n n n N n New PD patient Male Female PD at 31 st December Male Female n = PD count only = PD / HD+PD SECTION 12.2: ACHIEVEMENT OF SOLUTE CLEARANCE AND PERITONEAL TRANSPORT The percentage of patients achieving target solute clearance of 1.7 per week showed a further decline to 74 in 2014 (Table ).The figure had been static at 79 from with a slight drop to 78 in This should prompt some work to be done in identifying the causes for the declining rate. Wide inter-centre variation for delivered Kt/v was still seen in The proportion of patients achieving the delivered Kt/v varied from 47 to 89 5 th, 95 th percentiles) (Table ). Perhaps the PD practices in the better performing centres can be evaluated and shared with less well performing centres. The majority of the new PD patients had a low average and high average peritoneal membrane transport status with 39.3 and 33.4 respectively (Table ). Interestingly, most patients had a low average and high average membrane transport status even with 5 and 10 years dialysis vintage (Table ). As expected, residual urine volume showed a steady decline over time (Table and Figure ). However, on a positive note, up to a third of patients have a residual urine volume more than 400 ml/day after 4 or more years on PD ( Table ) Table : Distribution of delivered Kt/V, PD patients Year Numberof Patients Mean SD Median LQ UQ patients 1.7 per week

7 22nd Report of the PERITONEAL DIALYSIS Figure : Cumulative distribution of delivered Kt/V, PD patients Cumulative distribution Kt/V Figure : Variation in proportion of patients with Kt/V > 1.7 per week among PD centres patients with Kt/V >=1.7 per week (lower 95 CI, upper 95 CI) Centre Table : Variation in proportion of patients with Kt/V > 1.7 per week among PD centres, Year Number of centres Min 5 th Centile LQ Median UQ 95 th Centile Max Table : Peritoneal transport status by PET D/P creatinine at 4 hours, new PD patients Year n n n n n n n n n n Low Low average High average High TOTAL

8 PERITONEAL DIALYSIS 22nd Report of the Table : Peritoneal Transport Status (PET) with dialysis vintage Duration (Years) <1 1 <2 2 <3 3 <4 4 <5 n n n n n Low Low average High average High TOTAL Duration (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 Duration (Years) <1 1 <2 2 <4 4 or more n n n n <100 ml <400 ml <800 ml <1000 ml >=1000 ml TOTAL Figure : Residual Urine Volume in prevalent PD patients (2014) 100 <100 mls 100-<400 mls 400-<800 mls 800-<1000 mls >=1000 mls 80 Percent () <1 1-<2 2-<4 >=4 Duration (Years) 164

9 22nd Report of the PERITONEAL DIALYSIS SECTION 12.3: TECHNIQUE SURVIVAL ON PD There was no difference in technique survival (uncensored and censored for death and transplant) between the and time periods (Table and Figure a & b). In the latter period, technique survival was 93, 78 and 72 at 1, 3 and 4 years respectively (censored for death and transplant). The youngest age group (age <14 years) had better technique survival (uncensored for death and transplant) (Table & Figure a). However, after censoring for death and transplant, the age group 65 years fared best compared to other age groups after 3 years on PD treatment (Table & Figure b). Females consistently had better technique survival than their male counterparts (Table and Figure a & b). The technique survival (uncensored for death and transplant) was better for non-diabetic patients (Table & Figure a) but the difference was lost on censoring for death and transplant (Table & Figure b). There was a clear association between technique survival and solute clearance. Patients with Kt/V <1.7 had the worst technique survival. There was no initial difference in technique survival between Kt/V and Kt/V >2.0 but the curves started to diverge at 36 months, with better outcome in Kt/V >2.0 (Table & Figure ). Age group years, a history of peritonitis, male gender, obesity, low hemoglobin, low serum albumin, low serum calcium and low serum phosphate were associated with an increased risk of change in modality of renal replacement therapy (Table ). The commonest cause of PD drop out in year 2014 was peritonitis (13) followed by membrane failure (6) as shown in Table and Figure (a). Majority of the technique failure (72) occurred after 12 months of treatment (Table b). Table (a): Unadjusted technique survival by era and (uncensored for death and transplant) Era Interval (month) N SE N SE

10 PERITONEAL DIALYSIS 22nd Report of the Table (b): Unadjusted technique survival by era and (censored for death and transplant) Era Interval (month) N SE N SE Figure a: Unadjusted technique survival by era and (uncensored for death and transplant) Kaplan-Meier survival estimates, by Era Figure (b): Unadjusted technique survival by era and (censored for death and transplant) Kaplan-Meier survival estimates, by Era Cumulative survival Year Year Cumulative survival Year Year Duration in months Duration in months Table (a): Unadjusted technique survival by age (uncensored for death and transplant) Age group (years) Interval (month) n <= SE n SE n SE n SE 166

11 22nd Report of the PERITONEAL DIALYSIS Age group (years) Interval (month) n >=65 SE n SE N SE Table (b): Unadjusted technique survival by age (censored for death and transplant) Age group (years) Interval (month) n <= SE n SE n SE n SE Age group (years) Interval (month) n >=65 SE n SE N SE 167

12 PERITONEAL DIALYSIS 22nd Report of the Figure (a): Unadjusted technique survival by age (uncensored for death and transplant) Figure (b): Unadjusted technique survival by age (censored for death and transplant) 1.00 Kaplan-Meier survival estimates, by Age 1.00 Kaplan-Meier survival estimates, by Age Age 1-14 Cumulative survival Age Age Age Age>=65 Age 1-14 Age Age Duration in months Cumulative survival Age Age Age Age>=65 Age Age Duration in months 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 168

13 22nd Report of the PERITONEAL DIALYSIS Table (b): Unadjusted technique survival by gender (censored for death and transplant) Gender Interval (months) Male Female n survival SE N survival SE Table (a): Unadjusted technique survival by diabetes status (uncensored for death and transplant), Diabetes status Interval (month) Non diabetic Diabetic N survival SE N survival SE Figure (a): Unadjusted technique survival by Diabetes status (uncensored for death and transplant) Figure (b): Unadjusted technique survival by diabetes status (censored for death and transplant) 1.00 Kaplan-Meier survival estimates, by Diabetes 1.00 Kaplan-Meier survival estimates, by Diabetes Cumulative survival Non-diabetic Cumulative survival Diabetic Non-diabetic Diabetic Duration in months Duration in months 169

14 PERITONEAL DIALYSIS 22nd Report of the Table (b): Unadjusted technique survival by diabetes status (censored for death and transplant) Diabetes status Interval (month) Non diabetes Diabetic n survival SE N survival SE Table : Unadjusted technique survival by Kt/V, Kt/V Interval (months) < >2. 0 n SE N SE N SE Figure : Unadjusted technique survival by Kt/V, Kaplan-Meier survival estimates, by KTV Kt/V Cumulative survival Kt/V >2.0 Kt/V < Duration in months 170

15 22nd Report of the PERITONEAL DIALYSIS Table : Adjusted hazard ratio for change of modality, Factors n Hazardratio 95CI p value Age (years) Age 1 14 (ref*) Age (1.079;2.234) Age (0.766;1.663) Age (0.834;1.778) Age (0.700;1.468) Age (0.706;1.471) Age >= (0.646;1.425) Peritonitis No (ref*) Yes (8.090;10.590) <0.001 Diabetes Mellitus Non diabetic (ref*) Diabetic (0.851;1.161) Gender Male (ref*) Female (0.611;0.819) <0.001 Cardiovascular Disease No CVD (ref*) CVD (0.776;1.164) BMI < (0.698;1.131) <25 (ref*) >= (1.178;1.565) <0.001 Serum Albumin < (1.058;1.507) < (0.938;1.269) <45 (ref*) >= (0.393;1.622) Serum cholesterol (mmol/l) < (0.682;1.328) < (0.641;0.928) < (0.779;1.154) >=6.2 (ref*) Diastolic BP <70 70 <80 80 <90 (ref*) 90 <100 >=100 Hemoglobin (g/dl) <10 10 <12 (ref*) >=12 Serum calcium (mmol/l) < <=2.37 (ref*) > (0.808;1.363) (0.881;1.208) (0.983;1.442) (1.048;2.469) (1.197;1.590) < (0.713;1.178) (1.007;1.373) (0.838;1.200)

16 PERITONEAL DIALYSIS 22nd Report of the Factors n Hazardratio 95CI p value Calcium Phosphate product < (0.848;1.254) <4.5 (ref*) < (0.531;0.921) >= (0.605;1.414) Serum Phosphate (mmol/l) < (2.198;7.211) < <1.3 (ref*) < (0.684;0.984) < (0.622;1.111) >= (0.860;2.002) Kt/V < (0.904;1.301) (ref*) <= (0.995;1.366) Assisted PD Selfcare (ref*) Assisted (0.854;1.165) Table (a): Reasons for drop-out from PD program, Year n n n n n n N n n n Death Transplant Peritonitis Catheter related infection Membrane failure Technical problem Patient preference Others Unknown TOTAL

17 22nd Report of the PERITONEAL DIALYSIS Figure (a): Reasons for drop-out from PD program, Death Peritonitis Membrane failure Patient preference Unknown Transplant Catheter related infection Technical problem Others 100 Percent () Table (b): Drop-out rate from PD program with time on treatment, Year n n n n n n n n n n < 3 months <6 months 6 <12 months >=12 months TOTAL Table : Time on PD ( ) Months 1st Treatment (n=7316) 0 <

18 PERITONEAL DIALYSIS 22nd Report of the SECTION 12.4: PERITONITIS The median peritonitis rate for the year 2014 was 42.9 patient-months per episode (Table ). While this is a good result as compared to ISPD standards, there is a worsening trend for peritonitis rates in 2013 and 2014 compared to the achievemtents in 2011 and This may be due to an increased number of newer PD units over the last 2 years. There was a wide inter-centre variation at 67.6 versus 34 patient-months per episode. There was a similar incidence of gram positive (32.9) and gram negative peritonitis (31.8) (Table (a)). The commmonest gram positive pathogens were Staphylococcus aureus and Staphylococcus coagulase negative while Escherichia coli and Klebsiella were the main gram negative organisms isolated. Rates of fungal and mycobacterial peritonitis were very low, i.e. 2.2 and 0.8 respectively. Culture negative rates remain high at 25.6, although the rates in are slightly improved compared the earlier 5-year period Gram positive peritonitis showed better recovery rate compared to gram negative infections in both eras (Figures of (a) and (b)). Amongst the gram negative infections, Pseudomonas has the worst prognosis with only reported complete resolution and nearly one third resulting in catheter removal. The death rate was highest with fungal or Mycobacterial peritonitis. Comparing year vs, Streptococcal, Klebsiella and Polymicrobial organisms showed obvious improvement in peritonitis outcome in the latter era. In the era, polymicrobial peritonitis had a better resolution rate than in the previous era (51 versus 36) resulting in a lower death rate (23 compared to 43) (Figure c). The improvements in resolution of peritonitis were also noted with Streptococcal and Klebsiella peritonitis in year. Factors that significantly contributed to a lower risk of peritonitis were younger age group (age less than 14 years) and higher income group (Table ). The elderly age group (>55 years) and assisted PD (partially or complete) were shown to have a higher risk of developing peritonitis. Table : Variation in peritonitis rate (pt-month/epi) among PD centres, Year Number of centres Min 5 th Centile LQ Median UQ 95 th Centile Max

19 22nd Report of the PERITONEAL DIALYSIS Figure : Variation in peritonitis rate among PD centres, 2014 Rate, pt-month/epi Peritonitis rate (lower 95 CI, upper 95 CI) Centre Table (a): Causative organism in PD peritonitis, (A) Gram Positives N n n n n n n n n n Staph. aureus Staph Coagulase Neg Strep Others (B) Gram Negatives Pseudomonas Acinetobacter Klebsiella Enterobacter E.Coli Others (C) Polymicrobial (D) Others Fungal Mycobacterium Others (E) No growth TOTAL

20 PERITONEAL DIALYSIS 22nd Report of the Figure (b) Causative organism in PD peritonitis, Frequency Staph. Aureus Other Gram positive E.Coli Fungal Culture Negative Staph Coagulase Neg. Pseudomonas Polymicrobial Mycobacterium Table (a): Outcome of peritonitis by causative organism, Outcome Resolved Not resolved,catheter removed Death Total n N n n (A) Gram Positives Staph. Aureus Staph Coagulase Neg Strep Others (B) Gram Negatives Pseudomonas Acinetobacter Klebsiella Enterobacter E.Coli Others (C) Polymicrobial (D) Others Fungal Mycobacterium Others (E) No growth

21 22nd Report of the PERITONEAL DIALYSIS Table (b): Outcome of peritonitis by causative organism, Outcome Resolved Not resolved,catheter removed Death Total n N n n (A) Gram Positives Staph. aureus Staph coagulase neg Strep Others (B) Gram Negatives Pseudomonas Acinetobacter Klebsiella Enterobacter E.coli Others (C) Polymicrobial (D) Others Fungal Mycobacterium Others (E) No growth Figure (a): Outcome of peritonitis by causative organism, Figure (b): Outcome of peritonitis by causative organism, Resolved Not resolved, catheter removed Death Resolved Not resolved, catheter removed Death Percent () Percent () 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 Causative organism 177

22 PERITONEAL DIALYSIS 22nd Report of the Figure (c): Comparison of peritonitis outcome by causative organism by era, & Resolved Not resolved, catheter removed Death 100 Percent () Staph. Aureus Staph Coagulase Neg. Strep Others Pseudomonas Acinetobacter Klebsiella Enterobacter E.Coli Causative organism by era Others Polymicrobial Fungal Mycobacterium Others No growth Outcome of peritonitis by causative organism by era Table : Risk factors influencing peritonitis rate, Factors n Risk Ratio 95 CI P value Age (years) <= (0.664;0.986) (0.806;1.116) (ref*) (0.946; 1.263) (0.906;1.195) (1.028;1.357) >= (0.993;1.348) Gender Male (ref*) Female (0.963;1.103) Diabetes No (ref*) Yes (0.961;1.115) Income <RM 1000 (ref*) RM (0.758; 0.875) <0.001 RM (0.548;0.700) <0.001 RM (0.350;1.101) >=RM (0.122;1.958) Education Nil (0.914;1.189) Primary (0.930;1.090) Secondary (ref*) Tertiary (0.861;1.105) Assistance to perform CAPD Self care (ref*) Partially assisted (1.019;1.235) Completely assisted (1.058;1.261)