Strategies for Improving Long-Term Survival in Peritoneal Dialysis Patients

Abstract

The incidence and prevalence of ESRD in the United States continues to increase. Currently there are over 26,000 patients maintained on peritoneal dialysis. Mortality rates have fallen over the past several years, but long-term survival remains poor, with only 11% of peritoneal dialysis patients surviving past 10 years. Cardiovascular disease accounts for most deaths, and dialysis patients have many traditional and nontraditional cardiovascular risk factors. Lowering of these risk factors has not resulted in reduced cardiovascular morbidity and mortality in dialysis patients. Maneuvers to improve long-term peritoneal dialysis patient survival must therefore focus on modifiable risk factors including residual renal function, peritoneal membrane integrity, rate of infections, and peritoneal dialysis center size. This article reviews strategies for preserving residual renal function and peritoneal membrane integrity as well as strategies for reducing the rate of infections to enhance long-term survival in peritoneal dialysis patients.Clin J Am Soc Nephrol 5: 1123-1131, 2010. doi: 10.2215/CJN.04300709T he incidence and prevalence of ESRD continues to increase worldwide. In the United States alone there are over 480,000 patients on dialysis and the number of incident dialysis patients each year exceeds 100,000 (1). Peritoneal dialysis (PD) is an established treatment modality for patients with ESRD. Currently, 26,082 patients are maintained on PD in the United States (1). Mortality rates in ESRD patients have declined significantly over the past 20 years, but longterm survival remains poor, with the overall survival for all dialysis patients [hemodialysis (HD) and PD] being only 11%. These data were not censored for modality change, the effect of which is difficult to gauge. On a proportional basis, a greater percentage of PD than HD patients switch modality; however, in absolute numbers, more HD patients transition to PD than the reverse. Nevertheless, the overall adjusted probability of survival in incident PD patients at 1 year is 86.8%, but only 11.3% at 10 years (1). The reason for this dramatic decrease in patient survival over time is multifactorial and depends on several patient and dialysis center factors.There are several patient factors that affect survival on PD, most of which are nonmodifiable. Age, presence of diabetes, ESRD etiology, and ESRD vintage are all independent predictors of patient survival (2). For each 1-year increase in age, the risk of death increases by 4% [adjusted hazard ratio (HR) 1.04, P Ͻ 0.0001]. Patients with diabetes have a 30% increased risk of death compared with nondiabetic patients, and dialysis-naive patients have a 28% decreased risk of death compared with patients transferred from HD (2). Cardiovascular disease (CVD) accounts for most deaths in dialysis patients (approximately 50%). The genetics of the patient may be another nonmodifiable determinant of CVD. For example, a recent study of 1200 HD patients found an increased risk of CVD in patients with a specific complemen...

Risk Factors for Mortality in Stable Peritoneal Dialysis Patients

“…4 The comorbidities by the Davies index were ischemic heart disease, peripheral vascular disease, left ventricular dysfunction, diabetes mellitus (DM), systemic collagen vascular disease, and other significant pathologies. As described previously, the Davies index was categorized as low risk (0), intermediate risk (1)(2), and high risk (≥3). The following data during followup were documented from the patient records: use of icodextrin, statin, renin-angiotensin system (RAS) blockade, and peritonitis.…”

“…Accordingly, the number of patients on PD has been increasing. 1 The survival rate of PD patients is less as compared with that of the general population. Age, gender, underlying disease, the residual renal function (RRF), and infection are the classical independent predictors of PD patient survival.…”

“…However, improved care measures, such as preservation of the RRF, peritoneal membrane integrity, and control of infection, have resulted in a growing population of long-term survivors. 1,2 According to the ANZDATA Registry, the 3-year survival rate was 54% in 1994-1996 and 64% in 2003-2005. 3 Thus, patient survival has gradually improved with time.…”

“…However, most of the previous studies have included patients with a risk of early death. [1][2][3] There are few reports on the risk factors for stable PD patients who survive for a considerable time. This study addressed this issue.…”

Factors Associated with Above and Under 5-Year Survival in Peritoneal Dialysis Patients

“…All the modifiable factors (such as RRF, peritoneal membrane integrity, and PD-related infections) are strongly associated with long-term survival in PD patients. 11 The number of elderly patients with ESRD is increasing worldwide. Previous data indicate that age and presence of comorbid conditions play a significant role in dialysis mortality.…”