Patients Starting Peritoneal Dialysis: Where Are They 5 Years Later?

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Only 1 out of 7 patients who initiate peritoneal dialysis (PD) in the United States are still on PD at 5 years’ follow-up, reports a study in the American Journal of Kidney Diseases.

The retrospective study included 25,573 adults who initiated PD from 2008 through 2011, identified via the US Renal Data System (USRDS). Five-year follow-up data were analyzed to assess the proportion of patients transferring to hemodialysis (HD), along with the competing outcomes of death and kidney transplant. The patients’ mean age was 58 years: 56% were male, 71% white, and 22% African American. Mean baseline estimated glomerular filtration rate (eGFR) was 12.2 mL/min/1.73 m2.

During a median follow-up of 21.6 months, 41.2% of patients transferred to HD, 25.9% died, and 17.1% received a kidney transplant. The percentage of patients still on PD fell below 50% at 22.6 months; by 5 years, only 14.2% were still on PD.

Based on Medicare claims, 40.2% of patients developed peritonitis, which was a risk factor for HD transfer: hazard ratio (HR) 1.82. Other significant variables included African American race, higher body mass index, and diabetic or hypertensive kidney disease.

The investigators developed a tool for predicting patient transition from PD to HD, based on data obtained at enrollment in the USRDS. On the prediction tool, higher quartile scores were associated with a higher risk of HD transfer: HR 1.31 in the 2nd quartile, 1.51 in the 3rd quartile, and 1.78 in the 4th quartile, compared to the 1st quartile.

Peritoneal dialysis is an attractive option for some patients. However, many of those who initiate PD eventually transfer to HD. Early identification of patients likely to transfer from PD to HD might improve their subsequent care.

Based on analysis of nearly 30,000 patients initiating PD, only about 14% are still on this dialysis modality at 5 years’ follow-up. More than two-thirds transfer to HD or die by this time.

The report includes a prediction model for PD failure, accounting for the risks of competing outcomes. The researchers conclude, “Transition to HD needs to be considered for all new PD patients with favorable survival prognoses, especially when there is no plan for expedited kidney transplantation” [McGill RL, et al. Transfers to hemodialysis among US patients initiating renal replacement therapy with peritoneal dialysis. Am J Kidney Dis 2019; DOI: 10.1053/j.ajkd.2019.05.014].