During the span of a decade, improved outcomes seen for patients on peritoneal dialysis
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Between 1996 and 2015, researchers observed improved outcomes for patients on peritoneal dialysis. These outcomes included declining rates of mortality and a lower likelihood of transitioning to in-center hemodialysis.
“Transitions in dialysis modality often represent a change in patients’ clinical status and can be disruptive to care,” Nidhi Sukul, MD, of the University of Michigan and the Veterans Affairs Ann Arbor Health System, and colleagues wrote. “Our aim was to examine transitions among patients newly diagnosed with end-stage renal disease (ESRD) who had just started peritoneal dialysis (PD), including transition to in-center hemodialysis (in-center HD), as well as mortality and transplantation.”
Using the U.S. Renal Data System, researchers included 173,218 patients on Medicare who initiated PD between 1996 and 2011. All patients were followed for up to 3 years. Time was divided into periods of 1996 to 1999, 2000 to 2003, 2004 to 2007 and 2008 to 2011, with the researchers noting the 2012 to 2014 grouped cohort was not included in the analyses due to the unavailability of center-level factors.
Regarding trends in PD utilization, Sukul and colleagues observed the size of the incident PD population declined from 1996 to 2008 (12,730 to 9,507 patients), but subsequently increased by 77% in 2015 (16,819 patients). The prevalent PD population also declined between 1996 and 2000 (30,993 to 27,292 patients) and increased in 2015 (by 81%; 49,511 patients). Further, of all dialysis modalities, the researchers found the prevalence of PD decreased between 1996 and 2004 to 2011 (14% to 8%), but again increased to 10% between 2014 and 2015.
Regarding outcomes, Sukul and colleagues found recent incident PD patient cohorts had lower rates of death and transition to in-center hemodialysis (48% and 13% decline, respectively) than earlier cohorts.
Additional findings indicated that rates of transition to in-center hemodialysis and mortality were lowest in the 2008 to 2011 cohort and that longer-time on PD was associated with lower risk of transition to in-center hemodialysis (although, the researchers wrote, it was also associated with a higher mortality risk).
Moreover, while they observed an elevated risk of transition from PD to in-center hemodialysis for older patients and African American patients from 1996 to 2011, these risks were attenuated in recent years.
Finally, the researchers found patients treated in rural PD programs had a higher mortality risk than those in an urban PD facility (HR=1.05), while larger PD programs (25 or more patients) conferred lower mortality and transition to in-center hemodialysis than programs with six patients or less.
“While it is reassuring that rates of transition to in-center HD and mortality have declined in recent years, these two outcomes still affect a substantial number of patients, especially older patients, those with diabetes, and those dialyzing in smaller PD programs,” Sukul and colleagues concluded of their findings. “Future work should include evaluation of hospitalization and mortality around the time of transition, which may allow for a more in-depth understanding of unplanned transitions. These results will hopefully serve as steppingstones to better predict situations in which patients will need a transition to HD and provide enough lead-time to systematically prepare patients mentally and physically.”
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