MO706PATIENTS AND CENTER-RELATED FACTORS IN PERIOTONEAL CHOICE IN INCIDENT PATIENTS: A REGIONAL EXPERIENCE

Background and Aims Effective outpatient organization is essential in the management of patients with chronic kidney disease. Although peritoneal dialysis (PD) has many advantages it is still not popular. Method The aim of this study was to evaluate patient and center-related factors that affect the final choice of peritoneal dialysis (PD) versus hemodialysis (HD) in the Calabrian region (Italy). We analyzed 2 annual regional surveys performed by nephrologists (2017 and 2018) in incident dialysis patients. Collected factors included: early and late referral to the dialysis program, pre-dialysis participation in outpatient visits, first dialysis access [peritoneal catheter (PC), central venous catheter (CVC), arteriovenous fistula (AVF)], final dialysis treatment (HD or PD) and the care giver. Results The study sample included 296 incident patients (63% males) aged 66±15 years. Time to referral influenced the type of first dialysis access. Among patients with early referral, 35% initiated dialysis by a PC, 34% by AVF and 31% by CVC, while among those with late referral, only 5% started dialysis by a PC, 15% by AVF, and the majority (80%) by CVC (P<0.001). Time to referral was also associated with pre-dialysis visits (34%, 33% and 34% versus 5%, 22% and 73%, respectively, P<0.001). When evaluating clinical suitability for treatment modality, 54% of early referrals and 45% of late referrals were eligible for PD. The choice of dialytic modality was again related to time to referral: 38% with early referral chose PD compared to 15% of those with late referral (P<0.001). Furthermore, in patients who participated in the pre-dialysis program, 38% started PD versus 11% of patients that did not participate (P<0.001). The role of the caregiver remains uncertain. Conclusion These data confirm that a more attentive and dedicated organization of the pre-dialysis outpatient program would contribute to a greater expansion of the peritoneal dialysis program.

Restless Legs Syndrome in Dialysis Patients: Does the Dialysis Modality Influence Its Occurrence and Severity?

Background. Restless legs syndrome (RLS) is more prevalent in chronic kidney patients than in the general population, but it is often diagnosed late and its predictors are unknown. Purpose. To diagnose RLS in a group of chronic kidney patients on dialysis, determine its frequency and severity, compare the prevalence and severity of the condition among dialytic modalities, and identify possible predictive factors in this population. Methods. An observational and cross-sectional study with 326 patients who had been on dialysis for more than 3 months, 241 on hemodialysis (HD) and 85 on automatic peritoneal dialysis (APD), using the criteria established by the International Study Group on RLS for the diagnosis and the RLS Rating Scale to determine its severity. Results. RLS was diagnosed in 19.3% of the patients, 52.4% with severe or very severe forms. Patients with and without RLS did not differ in clinical and demographic characteristics and dialytic modality; however, patients on APD presented higher RLS severity compared to the HD group. Conclusions. RLS is frequent in dialysis patients and occurs predominantly in its most severe forms; the dialytic modality seems to have no influence on its occurrence; however, it is more severe in patients on APD.

Effect of Two-Hour Daily Hemodialysis and Sham Dialysis on Breath Isoprene Exhalation

Background Isoprene, a volatile hydrocarbon produced by the human organism, is currently being extensively investigated because the mechanisms underlying its endogenous origin are unknown and because experiments suggest it is toxic and cancerogenous. Previous reports of increases in breath isoprene concentrations during 4-hour, thrice-weekly hemodialysis, but not during continuous ambulatorial peritoneal dialysis, prompted us to assess the behavior of isoprene in another dialytic modality, i.e., short daily hemodialysis (short DHD). Furthermore, in order to determine whether removal of solutes and/or contact of blood with the dialytic membrane influenced the metabolism of isoprene, we performed a sham short hemodialysis session in a subgroup of 8 patients (sham short HD), i.e., with blood flowing through a dialyzer but without dialysate and ultrafiltration. Methods The present study evaluates the effects of a two-hour short DHD and a two-hour session of sham HD on isoprene breath levels, as determined by gas chromatography before, during and after sessions. Parallel analyses of ambient air and monitoring of blood pressure and heart rate were performed. Results Both short DHD and sham DHD induced an increase in breath isoprene exhalation in all patients without being associated with significant hemodynamic variations. Conclusion These findings suggest that the increase in breath isoprene after a session of hemodialysis is neither a reaction to mevalonate depletion nor to metabolic variations induced by the depurative effect, because these changes do not occur during sham HD. It is not related to hemodynamic changes because none were observed in this experimental model. The isoprene increase seems to be of metabolic origin and appears to be connected in some way with the extracorporeal circuit. These interesting findings provide a further impulse to study the biosynthetic pathways involved and to investigate the medical and biological significance of isoprene in humans. (Int J Artif Organs 2007; 30: 583–8)

Comparing Mortality Rates on Capd/Ccpd and Hemodialysis the Canadian Experience: Fact or Fiction?

← Objective To compare mortality rates on hemodialysis (HD) to rates on continuous ambulatory/cyclic peritoneal dialysis (CAPD/CCPD), to contrast our results with those of other recent investigations, and to discuss reasons for discrepancies. ← Data Sources Patient -specific data obtained from the Canadian Organ Replacement Register on patients initiating renal replacement therapy (RRT) between 1 January 1990 and 31 December 1995 (n = 14483). Recent mortality comparisons of CAPD and HD. ← Main Outcome Measures Mortality rate ratio (RR) based on “as-treated” (AT) analysis incorporating treatment modality switches and adjusting for age, primary renal diagnosis, and comorbid conditions using Poisson regression. Hazard ratios (HR) were estimated using Cox regression and based on an “intent-to-treat” (ITT) analysis wherein patients were classified based on dialytic modality received on follow-up day 90. ← Results Adjusted mortality rates were significantly decreased on CAPD/CCPD relative to HD [RR = 0.73, 95% confidence interval (CI) = (0.69, 0.77)] based on the AT analysis. Most of the protective effect of CAPD/CCPD was concentrated in the first 2 years of follow-up post-RRT initiation. Based on the ITT analysis, the estimated CAPD/ CCPD effect was greatly reduced, with HR = 0.93 (0.87, 0.99). ← Conclusions We provide further evidence that CAPD/ CCPD is not an inferior dialytic modality to HD, particularly in the short term. Comparing mortality rates on CAPD/ CCPD and HD is inherently difficult due to the potential for bias. Discrepancies between our results and those of previous investigations, and variability in findings among previous studies, relate to differences in clinical and demographic setting, patient populations, study design, statistical methods, and interaction between the dialytic modality effect and various other covariables.

The Study of Outcomes for Capd versus Hemodialysis Patients

Objective To discuss potential reasons for reported differences in the results of several recent studies comparing mortality risk among continuous ambulatory peritoneal dialysis (CAPD) and hemodialysis patients, and to assess the role of statistical methods and study design. Data Sources Recent published reports comparing mortality risk among patients treated with CAPD and hemodialysis. Conclusions Differences in study design, study populations, sample size, data collection, and availability of data likely account in part for the differences in available study results. The Cox model is a valuable tool, particularly for observational studies. Observed outcome differences for CAPD and hemodialysis patients may be due to either the dialytic modality itself or other factors such as differences in patient selection, practice patterns, dialysis dose, patient compliance, etc. Relative mortality rates for hemodialysis and CAPD patients may vary by country, as these factors may differ internationally. A randomized clinical trial is necessary to best determine the effect of the modality itself.