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      Prognostic implications of predialysis patients’ symptoms in peritoneal dialysis patients

      , , , ,

      Renal Failure

      Taylor & Francis

      Peritoneal dialysis, symptom, mortality, outcomes

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          As kidney disease progresses, patients often experience a variety of symptoms. There are very few studies reporting spectrum of predialysis patients’ symptoms in peritoneal dialysis (PD) patients. Furthermore, the clinical significance of predialysis patients’ symptoms for PD patients’ prognosis remains unknown.


          In this retrospective cohort study, patients who started PD during 1 January 2006 to 31 January 2018 were included. Patients’ predialysis symptoms and clinical parameters were obtained. Both the short- and long-term patients’ outcome were investigated by Cox regression and Kaplan–Meier’s survival analysis to identify the relationship between clinical symptoms and patients' mortality on PD.


          A total of 898 incident PD patients were included. The anorexia (58%) was the most common predialysis symptom in the present cohort, followed by insomnia (32.7%), fatigue (27.6%), syndromes of heart failure (27.6%), and nausea (20.5%). The only symptom significantly associated with both six-months and 12-months mortality on PD was nausea (HR 2.359, 95% CI 1.377–4.040, p=.002 and HR 1.791, 95% CI 1.176–2.729, p=.007, respectively). But in the long-term, anorexia (HR 1.392, 95% CI 1.070–1.811, p=.014) was the only symptom significantly associated with patient's all-cause mortality after adjusting for other confounding factors.


          Our study demonstrated that nausea and anorexia were the most important predialysis symptoms, which was associated with patients’ short- and long-term mortality on PD treatment, respectively. The results indicated that predialysis evaluation and management of symptoms of nausea and anorexia may be a possible way to improve patients’ outcome on PD.

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          Most cited references 18

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          A randomized, controlled trial of early versus late initiation of dialysis.

          In clinical practice, there is considerable variation in the timing of the initiation of maintenance dialysis for patients with stage V chronic kidney disease, with a worldwide trend toward early initiation. In this study, conducted at 32 centers in Australia and New Zealand, we examined whether the timing of the initiation of maintenance dialysis influenced survival among patients with chronic kidney disease. We randomly assigned patients 18 years of age or older with progressive chronic kidney disease and an estimated glomerular filtration rate (GFR) between 10.0 and 15.0 ml per minute per 1.73 m2 of body-surface area (calculated with the use of the Cockcroft-Gault equation) to planned initiation of dialysis when the estimated GFR was 10.0 to 14.0 ml per minute (early start) or when the estimated GFR was 5.0 to 7.0 ml per minute (late start). The primary outcome was death from any cause. Between July 2000 and November 2008, a total of 828 adults (mean age, 60.4 years; 542 men and 286 women; 355 with diabetes) underwent randomization, with a median time to the initiation of dialysis of 1.80 months (95% confidence interval [CI], 1.60 to 2.23) in the early-start group and 7.40 months (95% CI, 6.23 to 8.27) in the late-start group. A total of 75.9% of the patients in the late-start group initiated dialysis when the estimated GFR was above the target of 7.0 ml per minute, owing to the development of symptoms. During a median follow-up period of 3.59 years, 152 of 404 patients in the early-start group (37.6%) and 155 of 424 in the late-start group (36.6%) died (hazard ratio with early initiation, 1.04; 95% CI, 0.83 to 1.30; P=0.75). There was no significant difference between the groups in the frequency of adverse events (cardiovascular events, infections, or complications of dialysis). In this study, planned early initiation of dialysis in patients with stage V chronic kidney disease was not associated with an improvement in survival or clinical outcomes. (Funded by the National Health and Medical Research Council of Australia and others; Australian New Zealand Clinical Trials Registry number, 12609000266268.)
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            Adequacy of dialysis and nutrition in continuous peritoneal dialysis: association with clinical outcomes. Canada-USA (CANUSA) Peritoneal Dialysis Study Group.

            The objective of the study presented here was to evaluate the relationship of adequacy of dialysis and nutritional status to mortality, technique failure, and morbidity. This was a prospective cohort study of consecutive patients commencing continuous peritoneal dialysis in 14 centers in Canada and the United States. Between September 1, 1990 and December 31, 1992, 680 patients were enrolled. Follow-up was terminated December 31, 1993. There were 90 deaths, 137 transplants, and 118 technique failures. Fifteen withdrew from dialysis. Analysis of the patient and technique survival used the Cox proportional hazards model with adequacy of dialysis and nutritional status as time-dependent covariates. The relative risk (RR) of death increased with increased age, insulin-dependent diabetes mellitus, cardiovascular disease, decreased serum albumin concentration and worsened nutritional status (subjective global assessment and percentage lean body mass). A decrease of 0.1 unit Kt/V per week was associated with a 5% increase in the RR of death; a decrease of 5 L/1.73 m2 creatinine clearance (CCr) per week was associated with a 7% increase in the RR of death. The RR of technique failure was increased with decreased albumin concentration and decreased CCr. Hospitalization was increased with decreased serum albumin concentration, worsened nutrition according to subjective global assessment and decreased CCr. A weekly Kt/V of 2.1 and a weekly CCr of 70 L/1.73 m2 were each associated with an expected 2-yr survival of 78%.
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              Excess mortality due to interaction between protein-energy wasting, inflammation and cardiovascular disease in chronic dialysis patients.

              Protein-energy wasting (PEW), inflammation and cardiovascular diseases (CVD) clearly contribute to the high mortality in chronic dialysis. Our aim was to examine the presence of additive interaction between these three risk factors in their association with long-term mortality in dialysis patients. Patients from a prospective multi-centre cohort study among ESRD patients starting with their first dialysis treatment [the Netherlands Co-operative Study on the Adequacy of Dialysis-2 (NECOSAD-II)] with complete data on these risk factors were included (n = 815, age: 59 +/- 15 years, 60% men, 65% HD). Hazard ratios (HR) were calculated for all-cause mortality in 7 years of follow-up. The presence of interaction between the three risk factors was examined, based on additivity of effects. Of all patients, 10% only suffered from PEW (1-5 on the 7-point subjective global assessment), 11% from inflammation (CRP >/=10 mg/L), 14% from CVD and 22% had any combination of two components. Only 6% of the patients had all three risk factors. Patients with either PEW (HR: 1.6, 95% CI: 1.3-2.0), inflammation (1.6, 1.3-2.0) or CVD (1.7, 1.4-2.1) had an increased mortality risk. In patients with all three risk factors, the crude mortality rate of 45/100 person-years was 16 deaths/100 person-years higher than expected from the addition of the solo effects of PEW, inflammation and CVD. The relative excess risk due to interaction was 2.9 (95% CI: 0.3-5.4), implying additive interaction. After adjustment for age, sex, treatment modality, primary kidney diseases, diabetes and malignancy the HR for patients with all three risk factors was 4.8 (95% CI: 3.2-7.2). The concurrent presence of PEW, inflammation and CVD increased the mortality risk strikingly more than expected, implying that PEW interacts with inflammation and CVD in dialysis patients.

                Author and article information

                Ren Fail
                Ren Fail
                Renal Failure
                Taylor & Francis
                21 January 2021
                : 43
                : 1
                : 216-222
                Department of Nephrology, Peking University Third Hospital , Beijing, China
                Author notes

                Equal first author.

                CONTACT Wen Tang tanggwen@ 123456126.com Department of Nephrology, Peking University Third Hospital , 49 North Garden Rd, Haidian District, Beijing100191, China
                © 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Page count
                Figures: 3, Tables: 3, Pages: 7, Words: 3961
                Research Article
                Clinical Study


                outcomes, peritoneal dialysis, symptom, mortality


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