James Heaf Herlev Hospital University of Copenhagen Peritoneal Dialysis James Heaf Herlev Hospital University of Copenhagen

Choice of dialysis modality Herlev 2012

Peritonitis-free Survival Denmark 2000-2014

PD as a viable long term dialysis option James Heaf University of Copenhagen Herlev Hospital heaf@dadlnet.dk

The Poor and the Smart Home Dialysis World Leaders 2011 GDP/capita USD 36,667 38,222 10,247 7,855 67,723 56,202 55,158 46,098 5,678 52,232 46,142 38,589 99,622 3,113 38,589 USRDS 2013

Countries with High Home HD Prevalence

Corruption Index Transparency International 2011

Dialysis Costs Danish National Health Service Medical Technology Assessment Report 2006 Aim: 45% on Home Dialysis within 10 years 1 € = 85p www.nephrology.dk

Two basic types Automatic PD, APD CAPD

PD Variations Night Cycler APD CAPD Night (9 hours) Day (15 hours)

CAPD Variations Possibly Night cycler CAPD x 5 Gentle start PD Night (9 hours) Day (15 hours)

APD: Wet and Dry Days APD with wet day APD with Dry day Night (9 hours) Day (15 hours)

Osmotic Pressure and Ultrafiltration Icodextrin Extraneal® 4,25% 2,5% 1,5% KI 62;S81,21 2002

Peritoneal Equilibration Test (PET) Twardowski Perit Dial Bull 7:138 1987 82 68 52

2 year Survival in CAPD CANUSA Studiet. Churchill et al 2 year Survival in CAPD CANUSA Studiet. Churchill et al. J Am Soc Nephrol. 1998; 9:1285-92 Technique Patient Combined Survival 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 Neg UF CAPD Night This slide shows the results of computer modeling that characterizes the ultrafiltration (UF) potential of 1.5% dextrose by peritoneal membrane transport pattern—low, low-average, high-average, and high—using actual peritoneal transport data from patients on continuous ambulatory peritoneal dialysis.1 As expected, patients with high transport patterns exhibited the greatest decline in UF potential over time, while those with low transport patterns exhibited the most gradual declines. Nevertheless, during long dwell exchanges of about 10-14 hours, the majority of patients would likely experience negative net UF, regardless of transport status. This is explained by the relatively low concentration of glucose and its rapid diffusion across the peritoneal membrane, resulting in progressive loss of osmotic driving forces.1 APD Day Mujais S, Vonesh E. Kidney Int. 2002;62(suppl 81):S17-S22. 1.5% Glucose 1Mujais S, Vonesh E. Profiling peritoneal ultrafiltration. Kidney Int. 2002;62(suppl 81):S17-S22.

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 Multivariate analysis Johnson NDT 25,1973 2010

PD Prevalance Denmark 1990-2010 Mortality

HD vs. PD: Status 2014

PD vs. HD: Effect of Cohort Denmark 1990-2010 Adjusted for age, sex, renal diagnosis Comorbidity, & referral pattern Heaf PlosOne 2014

Effect of Cohort & Diabetes Heaf PlosOne 2014

Effect of Cohort & Age Heaf PlosOne2014

Effect of Cohort & Referral Early Referral Planned, out-patient Dialysis initiation Heaf PlosOne2014

Risk Factors for Residual Renal Function Loss Moist JASN 11:556-565, 2000 ** *** *** * * ** *** *** * *:p<0.05 **:p<0.01 ***:p<0.001 1843 patients 50% PD 50% HD Odds Ratio Multivariate Analyse

Peritoneal and Renal Clearance: Different Effects on Mortality Creatinine Clearance: Change per 1 ml/min Kt/V: Change per 0.1/week

Wu: QOL after 1 Year Wu JASN 15,743 2004 ** * ** ** * * * p<0.05 **p<0.01

CAPD på en tømmerflåde With thanks to Johan 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