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      Predictors of Death in Patients on Peritoneal Dialysis: The Missouri Peritoneal Dialysis Study

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          Abstract

          Background: The study was designed to identify predictors of death in subjects on peritoneal dialysis (PD). Methods: The population consisted of patients initiated on PD at the University of Missouri-Columbia and Dialysis Clinic Incorporated from January 1, 1990, through December 31, 1999. Baseline variables included demographics, clinical data, initial measures of nutritional status, adequacy, and transport characteristics. Co-morbidities were scored using a modified version of the Index of Coexistent Disease. Ongoing (during the course of PD) variables consisted of clinical characteristics and weighted time average of a number of laboratory, adequacy, and nutritional variables. The variables were screened using a univariate procedure, and then analyzed using stepwise logistic regression to evaluate their independent relation to death. Results: There were 105 men and 86 women – 180 Caucasians, 10 African-American, 1 Asian, mean age 61 ± 13 (SD) years, and mean duration of follow-up 21 ± 18 months. Eighty-two patients suffered the outcome of death. Lean body mass (LBM) at the initiation of PD was negatively associated with the risk of death (p < 0.01). In addition, the need for a partner to perform PD, total morbidity count, and the summated severity score of all co-morbidities were associated with an increased risk of death. The analysis of ongoing variables revealed that serum phosphate (negative association, p = 0.02) and number of hospitalization days per month on PD (p = 0.0006) were associated with an increased risk of death. Conclusion: Phosphate levels and LBM are strong negative predictors of death in PD subjects. Further, patients who need the assistance of a partner to perform PD have decreased survival.

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          Most cited references 16

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          Hemodialysis versus peritoneal dialysis: a comparison of adjusted mortality rates.

          Although kidney transplantation is the preferred treatment method for patients with ESRD, most patients are placed on dialysis either while awaiting transplantation or as their only therapy. The question of which dialytic method provides the best patient survival remains unresolved. Survival analyses comparing hemodialysis and continuous ambulatory peritoneal dialysis/continuous cyclic peritoneal dialysis (CAPD/CCPD), a newer and less costly dialytic modality, have yielded conflicting results. Using data obtained from the Canadian Organ Replacement Register, we compared mortality rates between hemodialysis and CAPD/CCPD among 11,970 ESRD patients who initiated treatment between 1990 and 1994 and were followed-up for a maximum of 5 years. Factors controlled for include age, primary renal diagnosis, center size, and predialysis comorbid conditions. The mortality rate ratio (RR) for CAPD/CCPD relative to hemodialysis, as estimated by Poisson regression, was 0.73 (95% confidence interval: 0.68 to 0.78). No such relationship was found when an intent-to-treat Cox regression model was fit. Decreased covariable-adjusted mortality for CAPD/CCPD held within all subgroups defined by age and diabetes status, although the RRs increased with age and diabetes prevalence. The increased mortality on hemodialysis compared with CAPD/CCPD was concentrated in the first 2 years of follow-up. Although continuous peritoneal dialysis was associated with significantly lower mortality rates relative to hemodialysis after adjusting for known prognostic factors, the potential impact of unmeasured patient characteristics must be considered. Notwithstanding, we present evidence that CAPD/CCPD, a newer and less costly method of renal replacement therapy, is not associated with increased mortality rates relative to hemodialysis.
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            What really happens to people on long-term peritoneal dialysis?

            Several risk factors for patients treated with peritoneal dialysis (PD) have now been identified. These include age, comorbid disease, nutritional status, loss of residual renal function (RRF) and high peritoneal solute transport. This is not the same, however, as knowing what actually happens to these patients, particularly in the long-term. The purpose of this review was to give as complete a description as is currently possible of the long-term PD patient. The literature was surveyed for publications that provide longitudinal cohort data of either selected or unselected patient groups. Detailed data from the Stoke PD Study is presented in the context of these studies. Three principle aspects of what really happens to patients were considered: (1) death, both cause and mode of death; (2) technique failure, with reference to peritoneal function and how the cause of technique failure related to patient survival; and (3) evolution of clinically relevant parameters of patients on PD, such as nutrition and peritoneal function. Sudden death and debilitation were the predominant modes of death, with sepsis playing a contributory role. Debilitation was important regardless of co-existent comorbid disease, and time to death was not influenced by the mode of death. Predominant causes for technique failure remain peritonitis and ultrafiltration, the latter becoming more important with time on treatment. Technical failure is associated with poorer survival, particularly when due to multiple peritonitis or failure to cope with treatment. Cox regression demonstrated that whereas low albumin, loss of RRF and high solute transport predicted patient death, only high solute transport predicted technique failure. Longitudinal changes over the first five years of treatment included loss of RRF, increasing solute transport and following an initial improvement in nutritional state, a decline after two years. Patients surviving long-term PD (at least five years, N = 25) were characterized by prolonged RRF, maintained nutrition and lower solute transport in the medium term. Several studies of long-term PD in the literature now complement each other in providing a picture of what really happens to PD patients. The links between loss of solute clearance and poor peritoneal ultrafiltration combining to exacerbate sudden or debilitated death and technique failure are emerging. For PD to be successful as a long-term therapy, strategies that maintain nutrition and preserve peritoneal membrane function must be developed.
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              Comorbidity assessment using the Index of Coexistent Diseases in a multicenter clinical trial.

              The Hemodialysis (HEMO) Study is a multicenter trial designed to determine whether hemodialysis dose and membrane flux affect survival. Comorbid conditions are also important determinants of survival, and thus, an accurate and reliable method to assess comorbidity was required. Comorbidity was being assessed at baseline and annually in the HEMO Study using the Index of Coexistent Disease (ICED). We describe the instrument, its implementation in the HEMO Study, and the results of comorbidity assessment in the first 1000 randomized patients in the trial. The ICED aggregated the presence and severity of 19 medical conditions and 11 physical impairments within two scales: the Index of Disease Severity (IDS) and the Index of Physical Impairment (IPI). The final ICED score was determined by an algorithm combining the peak scores for the IDS and IPI. The range of the ICED was from 0 to 3, reflecting increasing severity. Study personnel at 15 clinical centers were trained to update and abstract data from the dialysis medical records. Availability of data, measures of construct validity, and measures of reliability were adequate; 99.8% and 60.6% of patients had comorbid conditions in at least one IDS or IPI category, respectively. The distribution of patients by ICED level was 0 (0.2%), 1 (34.9%), 2 (31.2%), and 3 (33.7%). In multivariable analysis, the following factors were significantly associated with more severe comorbidity: older age, diabetes and other causes of renal disease, a lower level of education, employment status (unemployed and retired), longer duration of dialysis, and lower serum creatinine. There was a significant variation in the severity of comorbidity among clinical centers after adjustment for other factors. The R2 of the model was 25.3%, indicating that a substantial proportion of the variation in the ICED was not explained by these factors. We conclude that comorbidity assessment using the ICED is feasible in multicenter clinical trials of dialysis patients. There is a large burden of comorbidity in dialysis patients, which is not well explained by the cause of renal disease, demographic, and socioeconomic factors and common clinical and laboratory measurements. These variables should not be considered substitutes for comorbid conditions in case-mix adjustment. Comorbidity assessment is useful to describe the sample population, to improve the precision of the treatment effect, and to use possibly as an outcome measurement.
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                Author and article information

                Journal
                AJN
                Am J Nephrol
                10.1159/issn.0250-8095
                American Journal of Nephrology
                S. Karger AG
                0250-8095
                1421-9670
                2005
                October 2005
                12 October 2005
                : 25
                : 5
                : 466-473
                Affiliations
                aHarry S. Truman Memorial Veterans’ Hospital, bDivision of Nephrology and cDepartment of Biostatistics, University of Missouri-Columbia, Columbia, Mo., USA
                Article
                87876 Am J Nephrol 2005;25:466–473
                10.1159/000087876
                16127267
                © 2005 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                Tables: 4, References: 30, Pages: 8
                Product
                Self URI (application/pdf): https://www.karger.com/Article/Pdf/87876
                Categories
                Original Report: Patient-Oriented, Translational Research

                Cardiovascular Medicine, Nephrology

                Peritoneal dialysis, Phosphate, Mortality, Lean body mass

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