Peritoneal dialysis in Scotland: an analysis of complications and outcomes in a contemporary national cohort

[摘要] Peritoneal dialysis (PD) utilisation is falling in Western Countries. Concerns regardingreduced survival on PD, impact of inadequate dialysis on patient outcomes and the seriouscomplication of encapsulating peritoneal sclerosis (EPS) may be contributing to the declineof PD. The exact incidence of EPS has been difficult to establish because of differences indesign of published studies. In Scotland there was concern that the incidence of EPS wasincreasing, which prompted discussions about the future role and risks of PD. The aim ofthe MD was to establish an accurate incidence of EPS in Scotland and to examinecomplications and outcomes of PD patients to try to answer the question of who and forhow long PD should be used in our population. Since 1999 all adult renal units in Scotlandhave completed a PD Audit form 6 monthly for every PD patient which gives details of PDpopulation, source of new patients, reasons for stopping PD, causes of technique failure,details of all peritonitis episodes, adequacy test results and basic laboratory results. Thisprospectively collected data was linked to further demographic and laboratory data fromthe Scottish Renal Registry database for analysis. The analysis focussed on all incidentpatients commencing PD between 1st January 2000 and 31st December 2007 (n=1324),with follow-up to 30th June 2011. Our data analysis confirmed the ongoing fall in PDpopulation in Scotland, and greater usage of APD. Peritonitis rates have remained steady at1 episode every 19.9 months when averaged over the study period; similar to UK andAustralasian results but worse than North American centres. Several risk factors forperitonitis were identified in our population including unit, CAPD compared to APD,diabetes mellitus (DM) in females, older age, hypoalbuminaemia, and lower residual renalfunction (RRF) at the start of PD. We established that the overall risk of EPS is low, but ifPD is continued beyond 4 years the risk is substantial at 1 in 13 patients, with anexponentially increasing incidence with longer PD exposure. Survival is poor with 46.8%mortality at 1 year after diagnosis. No clear risk factors were apparent other than PDexposure. Analysis of patient survival identified several factors associated with poorersurvival including increasing age, hypoalbuminaemia and RRF at the start of PD, presenceof DM and multisystem primary renal diagnoses as well as having experienced peritonitis.The main causes of technique failure in our cohort include peritonitis (42.9%) andinadequate dialysis (22.1%). Predictors of technique failure include DM, lower RRF at thestart of PD and being treated in more recent PD eras. Overall analysis of the PD cohort hasshown that PD is a short-term treatment in Scotland with only a quarter of patientscontinuing PD beyond 3 years, with the remainder stopping for a transplant, techniquefailure or death. It is not possible to predict how long an individual patient will continuePD, but certain patients have poorer outcomes including the elderly (>70 years), those withDM and those hypoalbuminaemic at the start of PD. Therefore the actual number ofpatients who will continue PD long enough to be at significant risk of EPS is very small,and we believe the potential risk of EPS should not prevent patients from being offered PDin the first instance. Although some patients fare better on PD than others, we cannot statethat any specific patient group should not be offered PD on the basis of our analysesparticularly as we cannot show that they would have improved outcomes onhaemodialysis. For the minority of patients with ongoing technique success at 4 years wesuggest discussing ongoing PD, ensuring patients are informed about the EPS risk and arisk:benefit assessment of ongoing treatment should be decided on a case by case basis. Itis likely that clinician attitude are driving the decline of PD, in the absence of evidence toshow inferior outcomes on PD compared to HD. There would be an argument for activelyincreasing PD utilisation in Scotland, particularly among the elderly by expanding theassisted PD programs. Similarly, unless efforts are made to ensure adequate PD trainingand experience for nephrology trainees it is likely that PD will continue to decline.

[发布机构] University:University of Glasgow;Department:Institute of Cardiovascular and Medical Sciences

[关键词] R Medicine (General)