Researchers develop tool to predict patients on PD likely to be transferred to hemodialysis
Researchers have developed a predictive model to identify patients most at risk for transfer from peritoneal dialysis to hemodialysis.
“PD is an appealing treatment for patients with good self-care skills or a supportive home environment [as] residual kidney function is preserved longer than with hemodialysis,” Rita L. McGill, MD, MS, of the section of nephrology at the University of Chicago, and colleagues wrote. “However, PD use among prevalent dialysis patients is only 6.9%, and many patients electing PD ultimately transfer to hemodialysis [HD].”
They added, “Clinicians cannot readily identify which PD patients will transition to HD and thereby miss opportunities to prepare them for modality change. ... The risk for transition is to some degree intrinsic to individual patient characteristic but may also be influenced by events occurring after PD initiation, so we wanted preliminary models that accounted for both types of information.”
Using data from the U.S. Renal Data System, researchers conducted a retrospective cohort study of 29,573 patients who initiated PD therapy between January 2008 and December 2011. They built a competing-risk prediction tool which considered clinical characteristics at PD initiation, treatment history and peritonitis claims through Medicare. Patients were followed until modality change from PD to hemodialysis, kidney transplantation, death or July 1, 2015. Risk for transfer was classified at 1, 2, 3 and 4 years.
During follow-up, 41.2% of the cohort transferred to hemodialysis, 25.9% died and 17.1% underwent kidney transplantation. Researchers found the proportion of patients still receiving PD decreased to less than 50% at 22.6 months and that, at 5 years, 14.2% were still on PD.
In addition, peritonitis — claims present in 40.2% of patients — was associated with a higher rate of transfer to hemodialysis (HR = 1.82). Higher quartile scores of transfer risk were also associated with increased likelihood for transfer. Researchers noted that greater transfer risk correlated with African American race, higher BMI and diabetic or hypertensive kidney disease, while higher serum albumin level, employment, Asian American race and PD initiation at eGFR less than 15 mL/min/1.73m2 indicated lower risk.
“Fewer than 12% of patients initiating PD in the United States still used PD after 5 years,” the researchers wrote. They added, “Predictive models for PD failure that incorporate the hazards of competing outcomes may help improve the care of PD patients. ... Future studies incorporating longitudinal clinical information into prognostic models may further aid clinicians in determining the appropriate time-table for implementing vascular access plans.”
In a related editorial, Annie-Claire Nadeau-Fredette, MD, MSc, FRCPC, and Joanne M. Bargman, MD, FRCP, expressed concern that, after using the prediction tool, nephrologists may simply stop considering PD for high-risk patients instead of developing proactive solutions to support patients on the therapy.
They wrote, “We suggest that efforts be made to identify risk factors for PD technique failure to act on modifiable risk factors and offer enhanced clinical support and follow-up to vulnerable patients,” adding that home dialysis also requires adequate support and should not be considered an independent mode of care.
“Support of PD patients can be optimized through various strategies, including assisted PD, routine home visits from PD nurses or telehealth. ... In the end, before transferring PD patients to hemodialysis, we would hope that maximum efforts have been put into optimization of their full PD potential.” – by Melissa J. Webb
Disclosures: McGill reports receiving compensation for giving a lecture to Dialysis Clinic, Inc. personnel. Please see the study for all other authors’ relevant financial disclosures.