Peritoneal DialysisJames Heaf

Herlev HospitalUniversity of Copenhagen

Choice of dialysis modality Herlev 2012

HD Choice

HD Abdomen

HD Psych

HD Poor condition

HD Other

HD Switch to PD

PD Choice

HD Choice

HD Abdomen

HD Psych

HD Poor condition

HD Other

HD Switch to PD

PD Choice

Peritonitis-free Survival Denmark 2000-2014

00-04 05-120 1 2 3 4 5

Years

0,1

0,2

0,3

0,4

0,5

0,6

0,7

0,8

0,9

1,0

Pe

rito

niti

s-fr

ee

Su

rviv

al

PD as a viable long term dialysis option

James HeafUniversity of Copenhagen

Herlev Hospital

heaf@dadlnet.dk

The Fate of PD patients

0 1 2 3 4 5 6 7 8

Survival Time

0,0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

0,8

0,9

1,0

Cum

ulat

ive

Pro

port

ion

Sur

vivi

ng

Denmark 2000-2010

Death

Transplant

HD

The Poor and the SmartHome Dialysis World Leaders 2011

ScotlandRep. of Korea

NorwayUK^

NetherlandsCanada

ThailandFinlandSweden

DenmarkAustralia

ColombiaJalisco (Mexico)

New ZealandHong Kong

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0

PDHD

USRDS 2013

36,66738,22210,2477,85567,72356,20255,15846,0985,67852,23246,14238,58999,6223,113

38,589

GDP/capita USD

Countries with High Home HD Prevalence

Corruption Index

Transparency International 2011

Dialysis CostsDanish National Health ServiceMedical Technology Assessment Report 2006

Centre HD Self Care HD Home HD PD0

5

10

15

20

25

30

35

40

45

50€

x100

0/ye

ar

1 € = 85pwww.nephrology.dk

Aim: 45% on Home Dialysiswithin 10 years

Two basic types• Automatic PD, APD• CAPD

PD VariationsPD Variations

APD

CAPD

Night Cycler

Night (9 hours) Day (15 hours)

CAPD VariationsCAPD Variations

Night (9 hours) Day (15 hours)

Possibly Night cycler

Gentle start PD

CAPD x 5

APD: Wet and Dry DaysAPD: Wet and Dry Days

APD with wet day

APD withDry day

Night (9 hours) Day (15 hours)

Osmotic Pressure and Ultrafiltration

1,5%

IcodextrinExtraneal®

4,25%

2,5%

KI 62;S81,21 2002

Peritoneal Equilibration Test (PET)Twardowski Perit Dial Bull 7:138 1987

82

68

52

2 year Survival in CAPDCANUSA Studiet. Churchill et al. J Am Soc Nephrol. 1998; 9:1285-92

40

50

60

70

80

90

100

Teknik Overlevelse PatientOverlevelse

Kombineret

Surv

ival

(%

)

Langsom Mellem Langsom Mellem Hurtig Hurtig

Technique Patient CombinedSurvival Survival Survival

Slow Slow average Fast average Fast

PET og Ultrafiltration

2000 ml medium strength (2.2-2.5%) for 4 hours

Transport Type UF

Slow >650 ml

Slow average 370-650 ml

Fast Average 85-370 ml

Fast <85 ml

Ultrafiltration og transportstatus

-800

-600

-400

-200

0

200

400

0 2 4 6 8 10 12 14 16Time (hr)

Lav Lav-middel Høj-middel Høj

CAPDNight

APDDay

Neg UF

Mujais S, Vonesh E. Kidney Int. 2002;62(suppl 81):S17-S22. 1.5% Glucose

Outcome in high transporters is improved during recent years

Commencing 1990-1997 Commencing 1998-2005

Davies SJ, Kidney Int 70: S76-S83, 2006

ADP vs CAPD: Transport Status

0

0,5

1

1,5

2

2,5

High High average Low average Low.

Deat

h R

isk

APD

/CAPD

P<0.01

P<0.05

Johnson NDT 25,1973 2010Multivariate analysis

PD Prevalance Denmark 1990-2010

Mortality

HD vs. PD: Status 2014

3 6 9 12 15 18 21 24 27 30 360.30.40.50.60.70.80.9

11.11.21.31.41.5

Heaf NDT 02Termorhuizen JASN 03Liem KI 07McDonald JASN 09Weinhandl JASN 10Marshall AJKD 11Luijtgaarden NDT 11Mehrotra AIM 11Quinn JASN 11Yeates NDT 12Heaf PlosOne 14

Months

PD

/HD

Mo

rtal

ity

PD vs. HD: Effect of CohortDenmark 1990-2010

.5

.6

.7

.8

.9

1

1.1

1.2

1.3

1.4

1.5

Est

. tim

e-d

epen

dent

haz

ard

rat

io P

D v

s. H

D

0 .5 1 1.5 2 3 4 5 6

Time after ESRD (years)

1990-99 2000-10

Heaf PlosOne 2014

Adjusted forage, sex,renal diagnosisComorbidity,& referral pattern

Effect of Cohort & Diabetes

.5

.6

.7

.8

.9

1

1.1

1.2

1.3

1.4

1.5

Est

. tim

e-d

epen

dent

haz

ard

rat

io P

D v

s. H

D

0 .5 1 1.5 2 3 4 5 6

Time after ESRD (years)

DM: 1990-99 DM: 2000-10Non DM: 1990-99 Non DM: 2000-10

Heaf PlosOne 2014

Effect of Cohort & Age

.5

.6

.7

.8

.9

1

1.1

1.2

1.3

1.4

1.5

Est

. tim

e-d

epen

dent

haz

ard

rat

io P

D v

s. H

D

0 .5 1 1.5 2 3 4 5 6

Time after ESRD (years)

>= 65: 1990-99 >=65: 2000-10< 65: 1990-99 < 65: 2000-10

Heaf PlosOne2014

Effect of Cohort & Referral

.5

.6

.7

.8

.9

1

1.1

1.2

1.3

1.4

1.5

Est

. tim

e-d

epen

dent

haz

ard

rat

io P

D v

s. H

D

0 .5 1 1.5 2 3 4 5 6

Time after ESRD (years)

E&R: 1990-99 E&R: 2000-10Not E&R: 1990-99 Not E&R: 2000-10

Heaf PlosOne2014

E&R:Early ReferralPlanned, out-patientDialysis initiation

Risk Factors for Residual Renal Function LossMoist JASN 11:556-565, 2000

0 0,5 1 1,5 2 2,5 3 3,5

Fllow-up time

Female

Coloured

Diabetes

Heart Failure

Serum Calcium (mg/dl)

HD

ACE-I

Calciumantagonist

Odds Ratio Multivariate Analyse

1843 patients50% PD50% HD

*:p<0.05**:p<0.01***:p<0.001

*****

***

**

**

***

***

*

Peritoneal and Renal Clearance: Different Effects on Mortality

Cr Clear Kt/V Cr Clear Kt/V-50

-40

-30

-20

-10

0

10

CANUSA 96ADEMEX 02Rocco 02

%

Peritoneal Renal Creatinine Clearance:Change per 1 ml/min

Kt/V: Change per 0.1/week

Wu: QOL after 1 Year Wu JASN 15,743 2004

SymptomsCognitive

SleepSex

Body ImageQOL

FreedomTravel

RecreationFinance

WorkDiet

TimeAccess

50 60 70 80 90

PD

HD

HRQOL-ESRD Score

**

* p<0.05**p<0.01

***

**

*

*

CAPD på en tømmerflåde

With thanks toJohan Povlsen

Conclusions

• Economical compared to Center HD• Popular in Scandinavia• Better patient survival the first two years, possibly due to better

preservation of renal function• Not a longterm therapy• CAPD and APD choice based on transport characteristics and patient

wishes• A sensible choice for patients who want freedom from hospital and

freedom to travel