Peritoneal dialysis (PD) utilisation is falling in Western Countries. Concerns regarding reduced survival on PD, impact of inadequate dialysis on patient outcomes and the serious complication of encapsulating peritoneal sclerosis (EPS) may be contributing to the decline of PD. The exact incidence of EPS has been difficult to establish because of differences in design of published studies. In Scotland there was concern that the incidence of EPS was increasing, which prompted discussions about the future role and risks of PD. The aim of the MD was to establish an accurate incidence of EPS in Scotland and to examine complications and outcomes of PD patients to try to answer the question of who and for how long PD should be used in our population. Since 1999 all adult renal units in Scotland have completed a PD Audit form 6 monthly for every PD patient which gives details of PD population, source of new patients, reasons for stopping PD, causes of technique failure, details of all peritonitis episodes, adequacy test results and basic laboratory results. This prospectively collected data was linked to further demographic and laboratory data from the Scottish Renal Registry database for analysis. The analysis focussed on all incident patients commencing PD between 1st January 2000 and 31st December 2007 (n=1324), with follow-up to 30th June 2011. Our data analysis confirmed the ongoing fall in PD population in Scotland, and greater usage of APD. Peritonitis rates have remained steady at 1 episode every 19.9 months when averaged over the study period; similar to UK and Australasian results but worse than North American centres. Several risk factors for peritonitis were identified in our population including unit, CAPD compared to APD, diabetes mellitus (DM) in females, older age, hypoalbuminaemia, and lower residual renal function (RRF) at the start of PD. We established that the overall risk of EPS is low, but if PD is continued beyond 4 years the risk is substantial at 1 in 13 patients, with an exponentially increasing incidence with longer PD exposure. Survival is poor with 46.8% mortality at 1 year after diagnosis. No clear risk factors were apparent other than PD exposure. Analysis of patient survival identified several factors associated with poorer survival including increasing age, hypoalbuminaemia and RRF at the start of PD, presence of DM and multisystem primary renal diagnoses as well as having experienced peritonitis. The main causes of technique failure in our cohort include peritonitis (42.9%) and inadequate dialysis (22.1%). Predictors of technique failure include DM, lower RRF at the start of PD and being treated in more recent PD eras. Overall analysis of the PD cohort has shown that PD is a short-term treatment in Scotland with only a quarter of patients continuing PD beyond 3 years, with the remainder stopping for a transplant, technique failure or death. It is not possible to predict how long an individual patient will continue PD, but certain patients have poorer outcomes including the elderly (>70 years), those with DM and those hypoalbuminaemic at the start of PD. Therefore the actual number of patients who will continue PD long enough to be at significant risk of EPS is very small, and we believe the potential risk of EPS should not prevent patients from being offered PD in the first instance. Although some patients fare better on PD than others, we cannot state that any specific patient group should not be offered PD on the basis of our analyses particularly as we cannot show that they would have improved outcomes on haemodialysis. For the minority of patients with ongoing technique success at 4 years we suggest discussing ongoing PD, ensuring patients are informed about the EPS risk and a risk:benefit assessment of ongoing treatment should be decided on a case by case basis. It is likely that clinician attitude are driving the decline of PD, in the absence of evidence to show inferior outcomes on PD compared to HD. There would be an argument for actively increasing PD utilisation in Scotland, particularly among the elderly by expanding the assisted PD programs. Similarly, unless efforts are made to ensure adequate PD training and experience for nephrology trainees it is likely that PD will continue to decline.
| Identifer | oai:union.ndltd.org:bl.uk/oai:ethos.bl.uk:573868 |
| Date | January 2012 |
| Creators | Brown, Michaela Catherine |
| Publisher | University of Glasgow |
| Source Sets | Ethos UK |
| Detected Language | English |
| Type | Electronic Thesis or Dissertation |
| Source | http://theses.gla.ac.uk/4397/ |
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