1. La Dialisis Peritoneal como puente a la Hemodialisis
José Divino MD, PhD
VP Medical Affairs
Baxter Renal Division Latin America
Congreso de la Sociedad Española de Nefrologia
Cadiz
29 Septiembre 2007

2. The incidence of infection associated with
PD is no greater than that associated with HD.
Data from the USRDS demonstrate
that modality-related infections
(i.e., peritonitis and vascular access infection)
are lower in PD than in HD patients

3. What infections do dialysis patients get?
Infections directly related to the therapy:
Hemodialysis
Vascular access (catheters, grafts, fistulas)
Peritoneal Dialysis
Peritonitis, exit site infections
Other infections
Pneumonia
Skin infections (esp with poor circulation)
Dental, ENT (ear, nose, throat)

4. Bacteremia/Septicemia
Bacteremia is when a bacterial infection is found in the blood. This is documented by a blood culture growing out the organism. Patients may be mild to severely ill.
Septicemia is when a patient has bacteremia and is clinically ill. In the USRDS, it means the patient is admitted to hospital.
Local infections, e.g. skin infection, can cause bacteremia/septicemia, but not usually unless the local infection is severe.

5. Mortality from Infection: PD & HD
USRDS 2003 Annual Report

6. Reason for Admission: PD & HD
USRDS 2003 Annual Report

7. Bacteremia associated with PD is significantly less common
than with HD, and bacteremia associated
with peritonitis is rare

8. Overall first-year hospital admission rates for septicemia, by modality: adjusted rates
Figure 6.38
Incident dialysis patients with 90-day rule; adjusted rates adjusted for age, gender, race, & primary diagnosis. Patients with Medicare as a secondary payor or enrolled in an HMO on day 90 are excluded, as are patients with septicemia claims overlapping the start date of the followup period.

9. Organisms in Sepsis: HD &PD
USRDS 2003 Annual Report

10. Foley et al JASN 2004;15:

11. Foley et al JASN 2004;15:

12. Mortality after first bacteremia/septicemia event: adjusted mortality rates
Figure 6.39
Incident dialysis patients, 1996–2000, with 90-day rule & with Medicare as primary payor; adjusted rates adjusted for age, gender, race, primary diagnosis, & vintage. Patients without sepsis in the first year + 90 days after initiation are used as the reference cohort.

13. Fig. 1. Cumulative incidence of bacteremia or septicemia over time in
the Wave 2 population.

14. dramatically decreased over the last decade
 The incidence of peritonitis associated with PD has
dramatically decreased over the last decade

15. Why has peritonitis improved?
Advances in the systems
“Flush before fill”
Fewer connections
Better appreciation of surgical issues
Immobilization
Not related to catheter type
ISPD guidelines target 1 episode in every 18 patient months, but many programs do better and we should aim for better.

16. “Flush before fill”

17. Simplifying the Therapy UltraBag™ Integrated Disconnect System
Unique product design:
Asymmetrical Y-junction with straight drain path
Clinically validated for:
Reduced potential of re-circulation1
Reduced potential of re-infusion of bacteria into peritoneum1
Easy for patients to use
Reduced training time
An optimal PD Delivery System needs to incorporate both contamination protection AND flush efficiency
UltraBag distinguishes itself in the market due to it’s asymmetric Y. This design allows contaminents to flow directly away from the patient rather than re-circulate in the Y junction for possible re-infusion.
Kubey,W., Straka, P., Holmes, C.J. (1998, January 27,) Importance of Product Design on Effective Bacterial Removal by Fluid Convection in Y Set and Tiwnbag Systems. Blood Purification, 16,

19. Remón et al. Nefrología 26 Nº1: 45-55, 2006

20. Technique success with PD has shown continuing improvement over time

21. Improved PD
Reduced infection rates and easier to use systems have improved technique success with PD
Drop rates remain high, ranging from 10-50% per year in different parts of the world
Programs with greater experience have better outcomes

22. Mortality from Infection: PD & HD
USRDS 2003 Annual Report

23. Conclusions
There are advantages of PD in managing common clinical issues seen in dialysis patients, and improvements are being made in managing clinical issues specifically related to PD

24. Why Start on PD ? Better preservation of RRF.
Initial survival advantage relative to HD.
Better results after renal transplantation.
Preservation of vascular access

25. Access outcome 3.8 - 9.7 bacteremias per 1000 catheter days
Incidence of bacteremia
from temporary CVC’s
Internal Jugular 5.4% after 3 weeks
Femoral 10.7% after 1 week
bacteremias per
1000 catheter days
Oliver et al: KI 2000; 58: 2543

26. Hospitalization in the first year of RRT for ESRD
Prospective study of 526 incident patients starting RRT. 1 year follow up. Univariate analysis:
The most common single reason for admission was creation of & complications to vascular access for HD.
The use of temporary vascular access for HD were associated with prolonged hospitalization & repeated admissions.
Patients initially treated with HD rather than PD spent longer time in hospital & were more likely to be admitted.
Metcalfe et al. Q J Med 2003; 96: 899

27. The more than 10-fold increase in mortality in ESRD patients is mainly due to CVD and infections USRDS analysis stratified by gender, race, and age
CVD
Sepsis
0,001
0,01
0,1 1 10
100
25-34
35-44
45-54
55-64
65-74
75-84
85+
Age (years)
Annual mortality (%)
0.0001
0.001
0.01
0.1 10
100
25-34
35-44
45-54
55-64
65-74
75-84
85+
Age (years)
Annual mortality (%)
ESRD
ESRD GP GP
Foley et al. Am J Kidney Dis 1998,32:S112-S119
Sarnak et al. Kidney Int 2000 Oct;58(4):
Pecoits-Filho & Lindholm 2003

28. Central venous catheter (CVC) and its risks
They are exposed to risks of venous dialysis
catheter insertion, and catheter-related
infection and thrombosis.
Development of (long-term) access-failure is correlated with both use of central venous catheter, and premature puncture of access system at start of dialysis.
( Vanholder 2001)

29. Complications of catheter usage
Limited ability to provide
adequate dialysis
Related to size of CVC:
- Diameter
- Length
Recirculation
Placement problems
Complications
Tip location
Thrombosis
Extrinsic Intrinsic
Infection
Exit site
Tunnel
Catheter related
bacteremia

30. Peritoneal Dialysis as a bridge in chronic hemodialysis patients
Juan Fernández Cean

31. Three treatment options for
End Stage Renal Disease: HD PD RT

32. Vascular access in chronic HD patients :
Arteriovenous fistulae (AVF)
Arteriovenous grafts (AVG)

33. Vascular access in chronic HD patients :
Arteriovenous fistulae (AVF)
Arteriovenous grafts (AVG)
Venous Catheter (VC) is used as a bridge in CHD patients

34. The outcome of HD patients depends on the vascular access:
Arteriovenous fistulae (AVF)
Arteriovenous grafts (AVG)
Venous Catheter (VC)

35. Septicemia, access and cardiovascular disease in dialysis patients: The USRDS Wave 2 Study.
Ishani A, Collins A, Herzog C and Foley R. Kidney International (2005) 68,
Risk of bacterimia

36. Septicemia, access and cardiovascular disease in dialysis patients: The USRDS Wave 2 Study. Ishani A, Collins A, Herzog C and Foley R. Kidney International (2005) 68,
Risk of bacterimia

37. Annual mortality rate according to the vascular access
Type of vascular access and survival among incident HD patients: the Choices for healthy outcomes in caring for ESRD (CHOICE) study. Astor B et al. JASN, March 2005
Annual Mortality rate (%)

38. Type of vascular access and survival among incident HD patients: the Choices for healthy outcomes in caring for ESRD (CHOICE) study. Astor B et al. JASN, March 2005
Mortality (%) PD

39. Type of vascular access and survival among incident HD patients: the Choices for healthy outcomes in caring for ESRD (CHOICE) study. Astor B et al. JASN, March 2005
Mortality (%) PD

40. Haemodialysis vascular access problems in Canada: results from the Dialysis Outcomes and Practice Patterns Study (DOPPS II)
David C. Mendelssohn1, Jean Ethier2, Stacey J. Elder3, Rajiv Saran4,5, Friedrich K. Port3 and Ronald L. Pisoni3 NDT- March 2006; 21:
46 %
66 %
70 %
Fig. 2. Vascular access use among new ESRD (incident) patients in Canada, Europe and the USA in DOPPS II, 2002–2004 (n = 2025). Analysis included incident patients who entered DOPPS within 5 days of their first ever chronic HD treatment.

41. Haemodialysis vascular access problems in Canada: results from the Dialysis Outcomes and Practice Patterns Study (DOPPS II)
David C. Mendelssohn1, Jean Ethier2, Stacey J. Elder3, Rajiv Saran4,5, Friedrich K. Port3 and Ronald L. Pisoni3 NDT- March 2006; 21:
18 %
25 %
33 %
Fig. 1. Vascular access use among prevalent HD patients in Canada, Europe and the USA in DOPPS II, 2002–2003 (n = 6460). From data collected on a prevalent cross-section of HD patients at 252 dialysis units participating in DOPPS during 2002–2003 from Canada, Europe (France, Germany, Italy, Spain, Sweden and the UK) and the USA. Sample weights were employed to account for the differing proportions of patients sampled in each facility.

42. Colonia de bacterias dentro de la capa de biofilm, sobre la superficie de un catéter vascular
Raad I. Intravascular catheter related infections. Lancet 1998; 351:

43. Venous catheters are a necessary bridge to perform HD when there is an AVF-AVG complication or at the initiation of HD
Venous Catheter
AVF or AVG
AVF or AVG
Thromboses, infection
Venous Catheter
AVF or AVG
Initiation of HD

44. Three treatment options for
End Stage Renal Disease: HD PD RT

45. End Stage Renal Disease:
Three or four ?
treatment options for
End Stage Renal Disease:
HDcat PD
HDavf RT

46. Patients with venous catheter at the initiation of HD% % %
ESRD patients arriving in an emergency situation for the first dialysis treatment
Juan Fernández-Cean
ASN 37th Annual Meeting.2004

47. LA DIALYSIS OVERVIEW: ESRD AND PD Patients

48. Nephrol Dial Transplant (2002) 17: 2226-2230
Infective endocarditis in chronic haemodialysis: two treatment strategies
Juan Fernández-Cean, Asunción Alvarez, Sergio Burguez, Graciela Baldovinos, Patricia Larre-Borges and Mercedes Cha
Nephrol Dial Transplant (2002) 17:

49. Infective Endocarditis, incidence in general population and in chronic dialysis (1996)
Incidence per person- years
0.65 39 48 11
Abbott K et al. Hospitalization for Bacterial Endocarditis after initiation of Chronic Dialysis in the United States.
Nephron 2002;91:

50. Infective Endocarditis in chronic HD In-hospital mortality
Country Year Mortality
HD General
population
Francia % % Hanslik
NDT, 12:1301-2,1997
USA % Robinson,
AJKD 30:521-4, 1997
Uruguay % Fernández,
NDT 17: , 2002

51. Infective Endocarditis and vascular accessHD
Removal of the infected vascular access IE
HD with a new venous catheter (as a bridge)
AVF, AVG or Venous catheter
PD (as a bridge)

52. Infective endocarditis in chronic haemodialysis: two treatment strategies
Juan Fernández-Cean, Asunción Alvarez, Sergio Burguez, Graciela Baldovinos, Patricia Larre-Borges and Mercedes Cha
Nephrol Dial Transplant (2002) 17:
Period:
HD (n: 21) IE
HD (n: 9)
Vascular access removal
PD (n: 12)

53. Characteristics of patients
HD (9)
PD (12) P
All
Age
58 +16 NS
SEX m/f
4/5
7/5
11/10
Diabetes 2
Cancer 1 3
Valv. disease 4 8
Prosthetic valve
Time in HD (months)

54. Patients Number Mortality of deaths
Two treatment strategies in infective Endocarditis in HDC (n= 21) - Mortality
Patients Number Mortality of deaths
All %
HD %
P: 0.03
PD %
Nephrol Dial Transplant (2002) 17:

55. Infective endocarditis in chronic haemodialysis: two treatment strategies
Juan Fernández-Cean, Asunción Alvarez, Sergio Burguez, Graciela Baldovinos, Patricia Larre-Borges and Mercedes Cha
Nephrol Dial Transplant (2002) 17: 5
HD (9) 4
HD (21) 1 EI
PD (12) 3 8

56. PD could also be used as a bridge when there is an AVF complication or at the initiation of HD
Venous Catheter
AVF or AVG
AVF or AVG PD
Thromboses, infection
Venous Catheter
AVF or AVG
Initiation of HD PD

57. These results suggest that if PD is utilized as a bridge to HD, the hospitalization and mortality associated with infectious endocarditis in chronic HD patients may be significantly reduced.
In those case where the use of a central venous catheter is being considered, PD can be applied as a safer transitory solution, “a bridge”, while the patient receives an AV fistula and it matures

58. Considerar el uso de
DP como un “puente”
La colocación del catéter peritoneal asocia menos complicaciones
DP puede iniciarse inmediatamente luego de colocado el catéter
La frecuencia de complicaciones infecciosas es menor durante su utilización
Se puede planificar un acceso vascular definitivo para HD

59. Perspectives in renal medicine
Hemodialysis access failure: a call to action.
R Hakim and J Himmelfarb. Kidney Int, Vol 54 (1998), pp
Se debe considerar el uso de DP como un “puente” en los pacientes que presentan uremia avanzada y no son candidatos ideales para tratamiento prolongado con DP.
El inicio de tratamiento sustitutivo con DP, en tanto permite que madure la FAV o prótesis, puede mejorar la sobrevida de los accesos vasculares y del paciente.

60. Fernandez-Cean J et al, WCN 2007
Access related morbidity in hemodialysis and peritoneal dialysis patients
J. Fernández-Cean*1, G. Baldovinos1, A. Stein2, A. Varela1, V. Matonte3, N. Orihuela4, M. Garau1, I. Olaizola1, C. González1, R. López1, M. Mautone5, M. Pereyra1, Z. Lydia1, A. Petraglia1, R. Lombardi2, S. Orihuela4, T. Gómez4, A. Altuna1, C. Tenca1, E. Carbonell2
1HD, SARI, 2HD, INU, Montevideo, 3HD, CAMEDUR, Durazno, 4PD, Uruguayana, 5PD, Americano, Montevideo, Uruguay
Fernandez-Cean J et al, WCN 2007

61. Fernandez-Cean J et al, WCN 2007
Introduction:
Venous catheters (VC) are used as an unavoidable bridge in ESRD patients in HD, at the initiation or when there are complications of the arteriovenous access (AVA). Many publications stress that morbidity and mortality are higher in HD patients treated with VC.
Fernandez-Cean J et al, WCN 2007

62. Fernandez-Cean J et al, WCN 2007
Introduction:
Venous catheters (VC) are used as an unavoidable bridge in ESRD patients in HD, at the initiation or when there are complications of the arteriovenous access (AVA). Many publications stress that morbidity and mortality are higher in HD patients treated with VC.
In this study we analyze the different vascular access (VA) used in a population of chronic HD patients and the related morbidity. The results are compared with those of PD patients.
Fernandez-Cean J et al, WCN 2007

63. Introduction:
Venous catheters (VC) are used as an unavoidable bridge in ESRD patients in HD, at the initiation or when there are complications of the arteriovenous access (AVA). Many publications stress that morbidity and mortality are higher in HD patients treated with VC
In this study we analyze the different vascular access (VA) used in a population of chronic HD patients and the related morbidity. The results are compared with those of PD patients.
Our hypothesis is that PD could be safer than VC as a bridge in patients without a usable AVA.

64. Fernandez-Cean J et al, WCN 2007
Patients and Methods:
All HD and PD patients treated in 5 dialysis centers (3 HD centers and 2 PD
Centers) from January 1, 2004 to November 30, 2006 were included
Variables recorded in the observation period
Demographics: age, sex, diabetes
HD or PD access: type (AVA, VC, PD catheter)
date of creation and date of last use
Hospitalization days (Hosp-s)
Date of death, Transplantation or lost of follow-up.
Fernandez-Cean J et al, WCN 2007

65. Access related morbidity in hemodialysis
and peritoneal dialysis patients
319 patients HD PD
ALL
Patients
Diabetic (%)
Older than 65 (%)

66. Access related morbidity in hemodialysis
and peritoneal dialysis patients
319 patients HD PD
ALL
Patients
Diabetic (%)
Older than 65 (%)
Access changes
(changes per person-year) (0.50) (0.07) (0.38)

67. Access related morbidity in hemodialysis
and peritoneal dialysis patients
319 patients HD PD
ALL
Patients
Diabetic (%)
Older than 65 (%)
Access changes
(changes per person-year) (0.50) (0.07) (0.38)
AVA VC
Hosp-days per
1000 person-month

68. Fernandez-Cean J et al, WCN 2007
Conclusion:
These HD patients had a higher rate of change in dialysis access than the PD patients.
In this investigation, morbidity, measured by Hosp-d, is lower in PD than in HD patients with a venous catheter and the difference is statistically significant.
This result fits with our hypothesis and could be a reason to consider PD as a bridge in HD patients without a usable AVA.
Fernandez-Cean J et al, WCN 2007

69. Limitations:
Restrospective

70. Limitations:
Restrospective
Prevalent and incident patients

71. Limitations:
Restrospective
Prevalent and incident patients
Mortality was not analyzed

72. VASCULAR ACCESS SITE RELATED INFECTION IN DIALYSIS (V.A.R.I.):
a multicenter, prospective, Italian study.
The A.St.R.I.D. project
A.St.R.I.D.
Rio de Janeiro, 23 April 2007

73. Aim of the study
To assess the V.A.R.I. rates
To identify variables associated with them

74. Participating centres
11 dialysis units: 10-50
technical beds

75. Patients: 940 - age: 65±15 years
Study population
Patients: age: 65±15 years
- male 57 %
# vascular accesses:
Total follow-up: pt-months
Median patient f.u.: months
Total access f.u.: 334,306 days
# dialysis sessions: 142,883 treatments

76. Patient characteristics
# of patients %
Housing: alone ,6
nursing home ,1
family ,2
Malnourished: ,7
Diabetics: ,1
HBsAg positive: ,4
HCVAb positive: ,6
HIV positive: ,4
Karnofsky (median): 86 (IQR: 60-90)

77. Reported events
883 events, requiring hospitalization or antibiotic therapy
V.A.R.I.
18%
Not infectious
event
41%
Infection
not access related 41%

78. Distribution of pathogens%
S. aureus 41
26.1%
S. epidermidis 29
18.5%
Other Coagulase negative Staphylococci 39
24.8%
E. coli 25
15.9%
Klebsiella 1
0.6%
Enterobacter spp. 3
1.9%
P. aeruginosa 5
3.2%
S. malthophilia
Candida albicans
Other 8
5.1%
69.4

79. Factors associated to VARI-1*
Variable Category HR p
Sex F vs M
Type of vascular access
(vs AVF) Graft 6.43 <0.001
p CVC <0.001
t CVC <0.001
HCV yes vs no 1.34 NS
HBV yes vs no 1.65 NS
HIV yes vs no 1.49 NS
* Univariate Cox regression analysis

80. Factors associated to VARI-2*
Variable Category HR p
Number of dialysis
session per week NS
Housing
(vs. nursing home) living with family
living alone 0.89 NS
Karnofsky per 10 points increase 0.82 <0.001
Diabetes yes vs no 1.27 NS
Malnutrition yes vs no 1.38 NS
Impaired immune syst. drug related
disease related
* Univariate Cox regression analysis

81. Multivariate analysis
Only the type of access retained statistical significance

82. Infection rates
Infection risk per patient:
1.19 per 100 patient-month
Infection risk per access:
0.38 per 1000 access-days
0.26 per 1000 dialysis sessions

83. Infection-free survival
AVF
Graft
pCVC
tCVC
365
730
Kaplan Meier analysis

84. Conclusion The incidence of VARI is elevated in dialysis population
The pathogen responsible of infection is mainly Staph Aureus
CVC, either permanent or temporary, have a very high incidence of VARI
AVF remains the “preferred” vascular access and any effort for reducing the use of CVC must be done