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Broadening Options for Long-term Dialysis in the Elderly (BOLDE): Differences in quality of life on peritoneal dialysis compared to haemodialysis for older patients

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  • Lister Hospital, East and North Hertfordshire NHS Trust, ListerStevenage, UK

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Health-related quality of life (QOL) is an important outcome for older people who are often on dialysis for life. Little is, however, known about differences in QOL on haemodialysis (HD) and peritoneal dialysis (PD) in older age groups. Randomising patients to either modality to assess outcomes is not feasible. In this cross-sectional, multi-centred study we conducted QOL assessments (Short Form-12 Mental and Physical Component Summary scales, Hospital Anxiety and Depression Scale and Illness Intrusiveness Ratings Scale) in 140 people (aged 65 years or older) on PD and HD. The groups were similar in age, gender, time on dialysis, ethnicity, Index of Deprivation (based on postcode), dialysis adequacy, cognitive function (Mini-Mental State Exam and Trail-Making Test B), nutritional status (Subjective Global Assessment) and social networks. There was a higher comorbidity score in the HD group. Regression analyses were undertaken to ascertain which variables significantly influence each QOL assessment. All were influenced by symptom count highlighting that the patient's perception of their symptoms is a critical determinant of their mental and physical well being. Modality was found to be an independent predictor of illness intrusion with greater intrusion felt in those on HD. Overall, in two closely matched demographic groups of older dialysis patients, QOL was similar, if not better, in those on PD. This study strongly supports offering PD to all suitable older people.
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... Indeed, PD has been associated with a better quality of life (54)(55)(56), better outcomes in the first 2-3 years and preservation of residual kidney function (50,52,(57)(58)(59), and lower costs than in-centre HD (51,60,61). It enables the patient to preserve a high degree of autonomy, to travel and have an active life. ...
... The conditions that act as a barrier to self-care PD can be overcome by assisted PD, where a trained staff or family member provides daily dialysis assistance in the patient's home or in nursing home (64,66). Assistance can thus improve accessibility of home dialysis and survival in elderly or frail patient (29,66,67), whose quality of life may benefit most from home care dialysis (55). ...
Thesis
Peritoneal dialysis (PD) utilization has been declining over the past decades in Europe. Several reasons could explain this PD under-utilization, such as a low PD uptake and the persistence of an elevated rate of PD cessation. Strategic incentives to increase home dialysis, such as assisted PD programs, have been developed, however their impact remains under-described. In this work, we combined data of patients on PD from France and the UK, using statistical models including time-varying covariate, fractional polynomials and Cox regression with robust variance, to address some of the gaps in the current knowledge in PD under-utilization. With the present thesis, we have reported how the introduction of an assisted PD service positively influenced the uptake of PD and counterbalanced the decline in PD rates over time. In France, assisted PD currently relies on nurse assistance; which can be successfully promoted with economic incentives. Both PD cessation (due to either death or transfer to HD) and death linearly declined over time, and transfer to HD declined from 2011 mainly because of a significant decline in infection-related transfers. Finally, we have shown that time spent on HD before transfer to PD impacts patient survival but does not impact retransfer to HD. In lights of the results of this work, we believe that economic incentives promoting the reimbursement of assisted PD added with a shift in mentality and an increased commitment to PD could successfully increase PD rates and enable patients to have a free choice regarding their treatment modality.
... According to this model, patients on chronic PD would be considered underdialyzed. However, compared to HD patients, most PD patients do not have more uremic symptoms (27,28), worse quality of life or long-term survival (9-11), whether residual kidney function exists or not. When evaluating the preoperative state of dialysis patients, we should not only focus on the values of SCr and BUN on the laboratory test sheet but also on more comprehensive indicators such as anemia correction, volume status, cardiac function, mineral metabolism, nutrition status, and individual psychological status (29, 30). ...
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Background The associations between preoperative transfer to hemodialysis (HD) and postoperative outcomes in patients on chronic peritoneal dialysis (PD) remain unknown. We conducted this retrospective cohort study to investigate whether preoperative HD could influence surgical outcomes in PD patients undergoing major surgeries. Methods All chronic PD patients who underwent major surgeries from January 1, 2007, to December 31, 2020, at Peking University First Hospital were screened. Major surgery was defined as surgical procedures under general, lumbar or epidural anesthesia, with more than an overnight hospital stay. Patients under the age of 18, with a dialysis duration of less than 3 months, and those who underwent renal implantation surgeries and procedures exclusively aimed at placing or removing PD catheters were excluded. Patients involved were divided into either HD or PD group based on their preoperative dialysis status for further analysis. Results Of 105 PD patients enrolled, 65 continued PD, and 40 switched to HD preoperatively. Patients with preoperative HD were significantly more likely to develop postoperative hyperkalemia. The total complication rates were numerically higher in patients undergoing preoperative HD. After adjustment, the incidence of postoperative hyperkalemia or any other postoperative complication rates were similar between groups. There were no differences in long-term survival between the two groups. Conclusions It does not seem indispensable for PD patients to switch to temporary HD before major surgeries.
... Peritoneal dialysis (PD) can be used successfully in older people with ESKD 38 and results in similar HRQoL outcomes to in-centre HD. Among those able to perform autonomous PD, reported illness intrusiveness is lower than with in-centre HD 39 . Furthermore, assisted PD (asPD), whereby the PD technique is performed by a formal or informal caregiver, is associated with better treatment satisfaction among older people ...
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Supportive care (SC) is a multidimensional and person-centred approach to managing advanced CKD that engages the person and their caregivers in shared decision making from the outset. Rather than focussing on disease-specific therapies, SC is a collection of adjuvant interventions and adaptations to conventional treatments that can be used to improve the individual's quality of life. Recognising that frailty, multi-morbidity, and polypharmacy are more common among older people with advanced chronic kidney disease (CKD) and that people in this group tend to prioritise quality of life over survival as a goal of care, SC represents an important adjunct to disease-specific therapies in CKD management. This review provides an overview of SC in the older person with advanced CKD.
... Quality of life measures are considerably poorer in patients of all ages with impaired functional status on both haemodialysis (HD) and PD [6]. In relatively fit older patients who can manage PD themselves, the illness intrusiveness is lower on PD compared with matched patients on in-centre HD [7]. There are many advantages of dialysis at home using PD compared with in-centre HD for older patients as shown in Table 1. ...
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Introduction Availability of assisted PD (asPD) increases access to dialysis at home, particularly for the increasing numbers of older and frail people with advanced kidney disease. Although asPD has been widely used in some European countries for many years, it remains unavailable or poorly utilised in others. A group of leading European nephrologists have therefore formed a group to drive increased availability of asPD in Europe and in their own countries. Methods Members of the group filled in a proforma with the following headings: personal experience, country experience, who are the assistants, funding of asPD, barriers to growth, what is needed to grow, and their top 3 priorities. Results Only 5 of the 13 countries surveyed provided publicly funded reimbursement for asPD. The use of asPD depends on overall attitudes to PD with all respondents mentioning need for nephrology team education and/or patient education and involvement in dialysis modality decision making. Conclusion and call to action Many people with advanced kidney disease would prefer to have their dialysis at home, yet if the frail patient chooses PD most healthcare systems cannot provide their choice. AsPD should be available in all countries in Europe and for all renal centres. The top priorities to make this happen are education of renal healthcare teams about the advantages of PD, education of and discussion with patients and their families as they approach the need for dialysis, and engagement with policy makers and healthcare providers to develop and support assistance for PD.
... Peritoneal dialysis (PD) is a vital kidney replacement therapy. It offers a number of potential advantages for elderly patients, including better cardiovascular stability due to slower, continuous ultrafiltration, no need for vascular access, fewer technical requirements, better autonomy and independence, and less disturbing for patient's daily life (3,4). ...
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Objective The number of elderly patients on peritoneal dialysis (PD) has rapidly increased in the past few decades. We sought to explore the microbiology and outcomes of peritonitis in elderly PD patients compared with younger PD patients. Methods We conducted a retrospective study to analyze the clinical characteristics, causative organism distribution, and outcome of all PD patients who developed peritonitis between September 1, 2014 and December 31, 2020, from Second Xiangya Hospital, Central South University, China. Patients who experienced peritonitis were separated into elderly and younger groups. The elderly was defined as ≥ 65 years old at the initiation of PD. Results Among 1,200 patients, 64(33.9%) in elderly ( n = 189) and 215 (21.3%) in younger ( n = 1,011) developed at least one episode of peritonitis. A total of 394 episodes of peritonitis occurred in 279 patients. Of these, 88 episodes occurred in 64 elderly patients, and 306 episodes occurred in 215 younger patients. Gram-positive bacteria were the main causative organisms in elderly and younger patients (43.2% and 38.0%, respectively). Staphylococcus and Escherichia coli were the most common gram-positive and gram-negative bacteria, respectively. Fungal peritonitis in elderly patients was higher compared with younger patients (χ2 = 6.55, P = 0.01). Moreover, Acinetobacter baumannii (χ ² =9.25, P = 0.002) and polymicrobial peritonitis (χ ² = 6.41, P = 0.01) in elderly patients were also significantly higher than that in younger patients. Additionally, elderly PD patients had higher peritonitis-related mortality than younger patients (χ ² = 12.521, P = 0.000), though there was no significant difference in catheter removal between the two groups. Kaplan-Meier analysis showed that cumulative survival was significantly lower in elderly patients than younger patients (log rank = 7.867, p = 0.005), but similar technical survival in both groups (log rank = 0.036, p = 0.849). Conclusions This retrospective study demonstrated that elderly PD patients were more likely to develop Acinetobacter baumannii, fungal and polymicrobial peritonitis than younger PD patients. In addition, peritonitis-related mortality was significantly higher in elderly patients, whereas peritonitis-related catheter removal was comparable between elderly and younger PD patients. Understanding microbiology and outcome in elderly patients will help to reduce the incidence of PD-associated peritonitis and improve the quality of life.
Article
We conducted a systematic review and meta-analysis to determine the effect of the peritoneal dialysis (PD) modality, automated peritoneal dialysis (APD) or continuous ambulatory peritoneal dialysis (CAPD), on all-cause mortality (ACM) and PD failure. Studies were identified in PubMed, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), China National Knowledge Infrastructure, Weipu and Wanfang databases from database inception until April 1, 2021. The inclusion and exclusion criteria were based on the Population, Intervention, Comparison, Outcome, and Study (PICOS) design. Adjusted hazard ratios (HRs) with 95% confidence intervals (CI) were used to pool outcome estimates. Seventeen studies (more than 230,000 patients) were included. Our meta-analysis showed that compared with CAPD, APD demonstrated a significantly lower ACM risk (HR 0.87 [95% CI 0.77–0.99], p = 0.04), especially in studies involving an as-treated analysis (HR 0.75 [95% CI, 0.63–0.90], p = 0.00), published in Asia (HR 0.76 [95% CI, 0.67–0.86], p < 0.001) or Europe (HR 0.81 [95% CI, 0.74–0.89], p < 0.00), or published after 2012 (HR 0.82 [95% CI, 0.68–0.99], p = 0.04). However, APD was as effective as CAPD for PD survival (HR, 0.87 [95% CI, 0.75 to 1.00], p = 0.05 or HR, 0.90 [95% CI, 0.60 to 1.35], p = 0.61). Our results demonstrate a significant survival benefit for APD and provide evidence for increasing the global use of APD, especially in developing nations, where APD use has been hampered by a lack of reimbursement for care.
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ZUSAMMENFASSUNG Der vorliegende Beitrag befasst sich mit der Auswirkung der Peritonealdialyse bei geriatrischen Patienten*innen auf deren Lebensqualität. Studienergebnisse zeigen signifikante Unterschiede in Bezug auf die allgemeine Zufriedenheit der Patient*innen, den kognitiven Status und der sexuellen Funktion. Die Patient*innen erleiden weit weniger Symptome und weisen eine höhere Zufriedenheit mit der Behandlung auf. Weiterhin stellt die Peritonealdialyse für die Betroffenen eine weit weniger aggressive Behandlungsform dar. Die Art der jeweiligen Nierenersatztherapie sollte immer unter Berücksichtigung der Lebensqualität der Patient*innen gewählt werden.
Chapter
Peritoneal dialysis (PD) can be a superb renal replacement therapy, especially when used as the first renal replacement modality. Setting up, running, or expanding a home dialysis or PD services can be a daunting task. Successful units can grow and thrive only by proving success. This demands knowledge of the technique, careful patient selection and prescription, as well as monitoring of key metrics of success. A mandatory feature of successful programs is a dedicated, knowledgeable, and hardworking team, and building such a team is a key step in the provision of care. This chapter covers the practical aspects of setting up a service, how to maintain it, and what metrics to use to argue for more resources or to prove that you are delivering a quality service. It covers many comorbidities and how they affect PD as well as a discussion of pregnancy in PD. This chapter does not cover detailed prescription optimization, nor the treatment of peritonitis.KeywordsPeritoneal dialysisKey performance indicatorsHome dialysisService provisionCatheter place ment
Chapter
There is a large and growing geriatric population in patients with end-stage kidney disease (ESKD) requiring renal replacement therapy. Among incident ESKD patients, those older than age 75 years outnumber those aged 65–74 and have the highest incident growth rate. Contributing factors include increased prevalence of diabetes mellitus and hypertension, improved life expectancy, and increased willingness to initiate dialysis therapy in the older population. There are many geriatric considerations that must be taken into account when caring for older patients with ESKD. These include traditional geriatric syndromes (e.g., frailty, falls, cognitive impairment) along with renal specific considerations, such as renal replacement treatment modality and access considerations. Having an approach to these issues is essential to providing optimal, comprehensive care to older adults with renal disease.
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Background: Quality of life (QOL) is an important measure of the success of medicine. Choice of treatment is an important variable influencing QOL. We studied QOL in patients undergoing treatment for end-stage renal failure. Until June 1993 our patients needing dialysis could freely choose continuous ambulatory peritoneal dialysis (CAPD); however, since that time most patients have been forced to undergo CAPD because the hemodialysis program is full.Methods: We compared QOL in patients accepted before or after June 1993. Forty-five patients undergoing CAPD were studied during the period of choice compared with 44 who had no choice. Quality of life was studied by Bradburn Affect Scale, Mental Health Scale, Campbell Life Satisfaction, Perceived Health, Karnofsky Scale, Activity Scale, Physical Symptoms Scale, and desire for treatment change.Results: The patients undergoing CAPD in the no-choice group had a lower score than the choice population in 4 of the 7 QOL scales. The Mental Health Scale mean score was 18.4 compared with 15.5, and the patients ranking highest on the Mental Health Scale decreased from 33% to 18%, while those ranking lowest increased 7-fold from 2% to 14% comparing choice with no-choice group. The Bradburn Affect Scale score was +0.7 in the choice group compared with -0.3 in the no-choice group. There were no differences in age, sex, race, or treatment that explained the difference. Influence of other time-related factors is unlikely as there were no similar lower scores with time in the QOL reported by patients in the in-center or assisted self-care hemodialysis or transplant groups.Conclusion: Once the freedom of choice of treatment is gone from the patients undergoing CAPD their psychological QOL deteriorates.Arch Intern Med. 1997;157:1352-1356
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