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La Dialisis Peritoneal como puente a la Hemodialisis José Divino MD, PhD VP Medical Affairs Baxter Renal Division Latin America Congreso de la Sociedad.

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Presentation on theme: "La Dialisis Peritoneal como puente a la Hemodialisis José Divino MD, PhD VP Medical Affairs Baxter Renal Division Latin America Congreso de la Sociedad."— Presentation transcript:

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 USRDS 2003 Annual Report Mortality from Infection: PD & HD

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 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. Figure 6.38 Overall first-year hospital admission rates for septicemia, by modality: adjusted rates

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

10 Foley et al JASN 2004;15:

11

12 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. Mortality after first bacteremia/septicemia event: adjusted mortality rates Figure 6.39

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

14 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-circulation 1 – Reduced potential of re-infusion of bacteria into peritoneum 1 – Easy for patients to use – Reduced training time An optimal PD Delivery System needs to incorporate both contamination protection AND flush efficiency 1Kubey,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,

18

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 USRDS 2003 Annual Report Mortality from Infection: PD & HD

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 Oliver et al: KI 2000; 58: bacteremias per 1000 catheter days Incidence of bacteremia from temporary CVCs Internal Jugular 5.4% after 3 weeks Femoral 10.7% after 1 week

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 Foley et al. Am J Kidney Dis 1998,32:S112-S119Sarnak et al. Kidney Int 2000 Oct;58(4): CVD Sepsis ESRD GP Pecoits-Filho & Lindholm 2003

28 Central venous catheter (CVC) and its risks 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) They are exposed to risks of venous dialysis catheter insertion, and catheter-related infection and thrombosis.

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

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 Risk of bacterimia 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,

36 Risk of bacterimia 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,

37 Annual Mortality rate (%) 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

38 Mortality (%) 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 PD

39 Mortality (%) 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 PD

40 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. 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 %

41 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. 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: % 25 % 18 %

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

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

45 HD avf RT PD HD cat treatment options for End Stage Renal Disease: Three or four ?

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

47 LA DIALYSIS OVERVIEW: ESRD AND PD Patients

48 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 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 USA % Robinson, AJKD 30:521-4, 1997 Uruguay % Fernández, NDT 17: , 2002 Country Year Mortality HD General Francia % 17% Hanslik NDT, 12:1301-2,1997 population

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

52 IE PD (n: 12) HD (n: 21) HD (n: 9) 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: Vascular access removal

53 HD (9) PD (12) P All Age NS SEX m/f 4/5 7/5 NS 11/10 Diabetes 2 0 NS 2 Cancer 2 1 NS 3 Valv. disease 4 4 NS 8 Prosthetic valve 1 2 NS 3 Time in HD (months) NS Characteristics of patients

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

55 EI PD (12) HD (21) HD (9) 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:

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

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 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 Considerar el uso de DP como un puente

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 unpuente 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 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 Access related morbidity in hemodialysis and peritoneal dialysis patients Fernandez-Cean J et al, WCN 2007

61 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 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 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. Patients and Methods: Fernandez-Cean J et al, WCN 2007

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

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

67 HD PDALL Patients Diabetic (%) Older than 65 (%) Hosp-days per person-month AVAVC Access related morbidity in hemodialysis and peritoneal dialysis patients 319 patients Access changes (changes per person-year) (0.50) (0.07) (0.38)

68 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 Rio de Janeiro, 23 April 2007

73 Aim of the study 1.To assess the V.A.R.I. rates 2.To identify variables associated with them

74 Participating centres 11 dialysis units: technical beds

75 Study population Patients: age: 65±15 years - male 57 % # vascular accesses: 1221 Total follow-up: 10991pt-months Median patient f.u.: 11.2months Total access f.u.:334,306days # d ialysis sessions:142,883treatments

76 Patient characteristics # of patients% Housing:alone 72 7,6 nursing home 39 4,1 family 82988,2 Malnourished: 27929,7 Diabetics: 18920,1 HBsAg positive:41 4,4 HCVAb positive: 14715,6 HIV positive: 13 1,4 Karnofsky (median): 86(IQR: 60-90)

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

78 Distribution of pathogens Pathogenn% S. aureus % S. epidermidis % Other Coagulase negative Staphylococci % E. coli % Klebsiella 10.6% Enterobacter spp. 31.9% P. aeruginosa 53.2% S. malthophilia 53.2% Candida albicans 10.6% Other 85.1% 69.4

79 Factors associated to VARI-1* VariableCategoryHRp SexF vs M Type of vascular access (vs AVF)Graft6.43<0.001 p CVC22.47<0.001 t CVC28.58<0.001 HCV yes vs no1.34NS HBVyes vs no1.65NS HIVyes vs no1.49NS * Univariate Cox regression analysis

80 Factors associated to VARI-2* VariableCategoryHRp Number of dialysis session per week2.16NS Housing (vs. nursing home)living with family living alone0.89NS Karnofsky per 10 points increase0.82<0.001 Diabetesyes vs no1.27NS Malnutritionyes vs no1.38NS 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 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


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