| Abstract|| |
To determine the effect of selection of peritoneal dialysis patients who used automated PD (APD) as a first renal replacement therapy (RRT) option, we studied two groups of adult chronic kidney disease (CKD) patients treated with APD over a period of 4 years: group 1 included 30 patients in whom APD was the first choice for RRT and group 2 included 40 patients transferred from failed hemodialysis (HD) treatment. Both groups were matched for the original causes of CKD and comorbid conditions. However, group 1 had significantly higher residual renal function (RRF) than group 2 [glomerular filtration rate (GFR) 11.85 ± 4 mL/min and urine output 995 ± 465 mL/day vs. 3.69 ± 3.7 mL/min and 340 ± 447 mL/day, respectively, P = 0.0001] and Kt/v (2.7 ± 0.7 vs. 1.9 ± 0.4, respectively, P = 0.006). Most of the patients were compliant with their APD prescription, performed ideal PD techniques, achieved adequate dialysis and fluid ultrafiltration, and experienced much less than average infectious and non-infectious complications. However, group 1 achieved better clinical outcome than group 2, including relatively higher survival rate and kidney transplantation, significantly fewer episodes of peritonitis per year (0.09 vs. 0.14, respectively, P = 0.0001), higher serum albumin (2.95 ± 0.3 vs. 2.7 ± 0.27 g/dL, respectively, P = 0.035), hemoglobin (11.5 ± 0.9 vs. 10.6 ± 0.7 g/dL, respectively, P = 0.022) and lower parathormone levels (283 ± 117 vs. 389 ± 269 pg/mL, respectively, P = 0.02). They also maintained significantly higher total fluid removal compared to group 2 (1120 ± 330 vs. 560 ± 300 mL/day, respectively, P = 0.004), higher RRF (GFR 8 ± 2.6 mL/min vs. 1.8 ± 2.4 mL/min, respectively, P = 0.0001), and urine output (556 ± 447 mL/day vs. 240 ± 347 mL/day, respectively, P = 0.004), and significantly higher Kt/v (2.8 ± 0.7 vs. 1.9 ± 0.4, respectively, P = 0.2). In conclusion, in CKD patients, PD is a viable initial modality of RRT, and with better RRF may have a better outcome than as a secondary choice.
|How to cite this article:|
Karkar A, Abdelrahman M. Outcome of patients treated with automated peritoneal dialysis: Effects of selection of patients. Saudi J Kidney Dis Transpl 2011;22:40-8
|How to cite this URL:|
Karkar A, Abdelrahman M. Outcome of patients treated with automated peritoneal dialysis: Effects of selection of patients. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2020 Jan 25];22:40-8. Available from: http://www.sjkdt.org/text.asp?2011/22/1/40/74340
| Introduction|| |
Peritoneal dialysis (PD), when there are no contraindications, can be an excellent first treatment option for renal replacement therapy (RRT) program ,, with equivalent or better survival rate, especially among non-diabetic and younger diabetic patients, than hemodialysis (HD) during the first 1-2 years of therapy. ,,, Furthermore, PD has the benefits of preserving residual renal function (RRF), delaying the need for vascular access and helping patients with multiple vascular access failure, forming a better option for older age groups, especially those with cardiovascular disease, , and promoting home self-care. 
PD has become even more attractive following the recent availability of new PD solutions such as icodextrin and amino acid-based, , biocompatible PD fluids,  better connecting systems with significant reduction in peritonitis rate, and a new generation of automated cycler dialysis machines.  Studies have documented that if patients are given informed choice of dialysis treatment, 40-60% will chose PD modality. ,,, In addition, when comparing patient satisfaction with modality of HD versus PD as in CHOICE study, patients on PD therapy were more satisfied.  Furthermore, patients on PD modality from New Haven study were not only more satisfied with their care, but also they felt less significant impact of PD on their lives. 
Globally, it has been estimated that approximately one-third of PD patients are being main tained on automated PD (APD) treatment. ,,
In contrast with continuous ambulatory peritoneal dialysis (CAPD), the efficacy of APD, especially in high and high-average peritoneal transport membranes,  its higher  or similar , patient and technique survival rates, reduced peritonitis rates, ,, similar extracellular fluid volume and blood pressure control and sodium removal  or enhanced ultrafiltration,  avoidance of high intraperitoneal pressure and decreased mechanical complications,  home therapy and improved quality of life with more freedom for patients to fulfill their employment and lifestyle,  all enhanced the popularity of APD modality. These advantages have been confirmed even for anuric patients as demonstrated in the European Automated Peritoneal Dialysis Outcome (EAPOS) study 
The aim of this study was to examine the influence of selection of chronic kidney disease (CKD) patients for PD, whether applied as an initial option of RRT or as a second choice for patients with failed HD, on clinical outcome and on achievement and maintenance of successful APD treatment.
| Materials and Methods|| |
In our PD clinic, an APD program has been established in collaboration with Baxter Healthcare in 2004. We report our experience with 70 patients who were initiated and maintained on APD during 4 years.
Practical training of patients and/or relatives on APD Homechoice dialysis machine (theoretical and practical) lasted on an average of 2-3 weeks. Adequate training resulted in achieving full application of aseptic techniques, easy connection and disconnection of machine, priming time of about 10 min and total preparation of machine for about 15 min.
We analyzed the data of two subgroups of the 70 studied patients. In group 1 (30 patients), APD was the first choice and initial treatment option in newly recruited patients of stage 4 CKD from the outpatient clinic. Patients were selected according to their clinical suitability and on the basis of their informed choice and decision. This group had the chance of receiving adequate education and training before com-mencing APD treatment. The age in this group varied between 14 and 92 years (50 ± 20 years) and included 9 males and 21 females [Table 1]. The main original diseases in these patients included diabetic nephropathy in 5 3% (n = 14), hypertension in 23% (n = 7), and glomerulonephritis in 14% (n = 6). The comorbid conditions included diabetes mellitus in 53% of patients, hypertension in 60%, and cardiovascular disease in 30%; none of the patients developed malignancy or were serologically positive for hepatitis C or hepatitis B.
|Table 1: Initial parameters in patients who selected APD as the first RRT choice compared with those of patients transferred from HD to APD as the second RRT choice.|
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In group 2 (40 patients), APD was initiated upon transfer from HD. The patients were on regular HD treatment from 7 to 118 months before the transfer; the majority (n = 33, 82.5%) were transferred due to failed vascular access and the rest (n = 7, 17.5%) were offered APD to suit their lifestyle and accepted it as a second RRT choice. All the patients in group 2 did not have equivalent pre-dialysis chance of education and preparation as in group 1, but received adequate PD practical training. Age of the patients in this group varied between 16 and 96 years (61 ± 17), which was significantly higher than in the first group (P = 0.01), and there were equal numbers of male and female patients (n = 20). The frequency of main original diseases, and comorbid conditions were not statistically different from those of group 1 patients [Table 1], but three patients were positive for antibodies to hepatitis C.
At the beginning of the study, the initial hemoglobin, parathormone levels, and biochemical parameters, including serum albumin, were not statistically different between both groups. However, patients in group 1, as expected, had statistically higher initial RRF, total fluid removal, creatinine clearance and dialysis adequacy, as shown in [Table 1].
The usual average PD prescription included the following steps: APD starts at 10 p.m.-12 p.m. and ends at 8 a.m.-10 a.m. The dialysis duration time lasts 8-12 hours, 4-6 cycles/ night, infused volume 2-2.5 L/cycle of 1.36% solution, dwell time 1-2 hours, daytime dwell (when indicated) 12-16 hours and total fill volume used 10-14 L/night, though all patients were supplied with 15 L/night. Adequacy was tested after 1 month and peritoneal equilibration test (PET) was performed after 6 weeks. There was no low transporter type of peritoneal membrane among all patients, but similar number with low-average and high-average membrane, with only two patients with high transporter peritoneal membrane.
The patients were evaluated on a regular basis in the PD clinic to adjust PD prescription according to the patients' needs, and to ensure the adequacy of treatment and absence of complications. Patients were instructed and encouraged to contact the PD team during and after the working hours in case of any sign or symptom or query regarding any technical problem.
| Statistical Analysis|| |
Continuous variables were reported as mean ± standard deviation (Mean ± SD) and compared using Student's "t" test. A P value <0.05 was considered statistically significant. Statistical analysis was performed using Medcalc software (Broekstraat 52, B-9030, Mariakerke, Belgium) version 10.3.2.0 ( http://www.medcalc.b6e ).
| Results|| |
[Table 2] shows the results at the end of 4 years treatment with APD. Both studied groups achieved and maintained adequate therapy, with no significant difference in biochemical results of urea, serum creatinine and creatinine clearance [Table 2]. However, group 1 in comparison with group 2 maintained significantly higher serum albumin (2.95 ± 0.3 vs. 2.7 ± 0.27 g/dL, respectively, P = 0.035) and hemoglobin (11.5 ± 0.9 vs. 10.6 ± 0.7 g/dL, respectively, P = 0.022) and parathormone levels (283 ± 117 vs. 389 ± 269 pg/mL, respectively, P = 0.02). Furthermore, there was a significant difference between group 1 and 2 in dialysis adequacy (Kt/v 2.8 ± 0.7 vs. 1.9 ± 0.4, respectively, P = 0.02), total fluid removal (1120 ± 330 vs. 560 ± 300 mL/day, respectively, P = 0.004), and RRF (urine output 556 ± 447 vs. 240 ± 347 mL/day, respectively, P = 0.013; and GFR 8 ± 2.6 vs. 1.8 ± 2.4 mL/min, respectively, P = 0.0001). In addition, patients in group 1 required lesser time in comparison to group 2 patients (6.5 ± 1.2 vs. 12 ± 6 days, respectively, P = 0.0027) to achieve adequate training following Tenckhoff catheter insertion, and consequently, shorter hospital stay.
|Table 2: Post 4 years APD treatment parameters in patients who selected APD as the first RRT choice compared with those of patients transferred from HD to APD as the second RRT choice.|
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[Table 3] shows the infection complications in the study groups. In group 1, peritonitis affected only two patients (7%), with one episode in 134 months of treatment, which was significantly lesser than in patients in group 2, where there were five patients (13%) with one episode in 87 months of treatment (0.09 vs. 0.14 episodes/year, respectively, P = 0.0001). In contrast, exit site infection affected four patients in group 1 and 11 patients in group 2; however, there was no significant difference in exit site infection between both the groups (0.18 vs. 0.30 episodes/year, respectively). Finally, there was only one episode of tunnel infection in group 1 (a rate of 1 in 267 months of treatment; 0.05 episode/year). Peritonitis in group 1 was due to Klebsiella in one patient and there was no growth in the second patient, while Pseudomonas was the cause of peritonitis in one case in group 2 and four patients showed no bacterial growth. In both the groups of patients, however, there was no gram-positive bacterial growth of Staphylococcus or Streptococcus in peritoneal fluid culture. In contrast, Staphylococcus aureus was a more common organism cultured from exit site infection in patients in group 2. Most patients were treated adequately and achieved complete response to treatment in both groups.
|Table 3: Comparison of infectious complications between APD as an initial or second choice modality of renal replacement therapy.|
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Small number of patients in groups 1 and 2 suffered non-infectious complications, which were not statistically significant. These included catheter migration (4 vs. 3, respectively) and ultrafiltration failure (2 vs. 2, respectively). There were no reported cases of leak, inflow or outflow obstruction, or development of hernia or hydrocele.
[Table 4] shows the outcome of the study patients. At the end of 4 years treatment with APD, 20% of patients (n = 6) in group 1 transferred to HD versus 32% (n = 13) in group 2. This was due to catheter migration (n = 4 vs. n = 3, respectively), ultrafiltration failure (n = 2 vs. n = 2, respectively), poor compliance (n = 0 vs. n = 5, respectively), peritonitis (n = 0 vs. n = 2, respectively) and exit site infection (n = 0 vs. n = 1, respectively). There were 20% of patients (n = 6) transplanted in group 1 compared with 5% (n = 2) in group 2 and 90% (n = 27) survival rate in group 1 versus 80% (n = 42) in group 2 with overall survival rate of 84%.
|Table 4: Outcome of patients in both groups after 4 years of treatment with APD.|
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| Discussion|| |
Most of our APD patients were compliant with their prescription, performed ideal PD techniques and have achieved adequate dialysis and fluid ultrafiltration and experienced much less than average infectious and non-infectious complications.
As a first choice modality, PD offers better preservation of RRF,  lower risk of infection with hepatitis B and C, , better outcome after transplantation with lower incidence of acute kidney injury and delayed graft function, preservation of vascular access and lower costs than HD.  However, HD and PD have been regarded as complementary methods of RRT, where their use is based on medical indications and contraindications, as well as patient's preference in order to achieve best outcomes for the patients. , It has been reported that there is 10-20% of PD patients transferred annually to HD due to technical failure,  but there has been much smaller proportion change modality from HD to PD, , predominantly due to vascular access problems, cardiac disease or patients preference. ,, In these studies, the clinical outcome and survival rate were worse in transferred patients from HD to PD than in patients who had initiated dialysis with PD. This was not attributed to the difference in RRF,  but to numerous comorbid conditions, including cardiovascular diseases, diabetes mellitus and low serum albumin. In comparison, a recent study by Liberek et al,  has shown that the outcome of patients transferred from HD may be similar to that achieved in patients in whom PD was the first choice therapy.
However, in their transferred group from HD to PD and when compared with first choice PD group, there were higher levels of hemoglobin, similar levels of serum albumin, insignificant difference in body mass index and significantly less patients with diabetes mellitus, findings that may confirm the influence of precomorbid conditions on clinical outcome in transferred patients. In our study, patients treated with APD as a first choice option maintained significantly higher serum albumin and hemoglobin levels and significantly lower nPCR and PTH levels. They have also maintained significantly higher RRF, total fluid removal and adequate dialysis, in addition to shorter post Tenckhoff catheter insertion training period and hospital stay. There were as well significantly fewer incidences and episodes of peritonitis, fewer patients transferred back to HD (none of them transferred because of poor compliance or unresolved infectious complications), higher patient survival rate, and more patients achieved successful kidney transplantation.
Our findings are in agreement with earlier studies, ,, where clinical outcomes were be tter in patients who selected PD as their first modality of RRT than in patients transferred from HD to PD. It is important, however, to notice that the first group patients were significantly at younger age, and as expected, enjoyed significantly higher RRF, creatinine clearance, Kt/v and total fluid removal than the second group patients. The better clinical outcomes can also be attributed to better patients' pre-dialysis educational and training program  and the experience and commitment of the PD team, the value of which has been confirmed by other studies. , These findings, together with avoidance of vascular access creation and better quality of lifestyle and safety, are in favor of selection of PD as an initial modality choice of RRT, which are compatible with the findings of other reported studies. ,,,,,
The comparable clinical outcome of the study groups may be due to comparable original causes of renal failure, insignificant differences in initial laboratory parameters and similar initial comorbidities despite the differences in the adequacy of dialysis.
Infectious complications and, in particular, repeated episodes of peritonitis were less frequent when compared to other studies. ,, However, rates and episodes of peritonitis were significantly more often in patients transferred from HD to APD than in those who had APD as a first choice, probably due less training and education for the transferred patients. This demonstrates the benefits of early preparation of renal failure patients approaching stage IV CKD for RRT and, in particular, when selecting PD treatment as the first choice option. 
In conclusion, in CKD patients, PD is a viable initial modality of RRT, and with better RRF, may have a better outcome than with PD as a secondary choice.
| Acknowledgment|| |
The authors are grateful for the assessment and data collection given by Mrs. Huda Al Jafary.
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Department of Nephrology, Kanoo Kidney Centre, P.O. Box 11825, Dammam 31463
[Table 1], [Table 2], [Table 3], [Table 4]