3. IRC OUTLINES 1. New Classification of CKD according to KDIGO Dec 2012 2. Prevalence of CKD 3. Prevalence of RRT 4. Description of Integrated Renal Care (IRC) 5. Why PD is the first therapy in IRC

6.  US CKD prevalence (11.0% in 1988 through 1994 and 11.7% in 1999 through 2000).  Was 26 million out of approximately 200 million United States residents aged 20 and older.  Total CKD prevalence in Norway was 10.2%  Saudia Arabia 6%.  Iran 18.9%  Indonesia 8.6%  Of these 65.3 % had CKD stage 3 or 4. CKD

7. KDIGO 2012 Clinical Practice Guidelines for the Evaluation and Management of CKD  We recommend that CKD is classified based on cause, GFR category, and albuminuria category (CGA).  Assign cause of CKD based on presence or absence of systemic disease and the location within the kidney of observed or presumed pathologic-anatomic findings. (Not graded)  Assign GFR categories as follows (Not Graded) Staging of CKD

8. GFR Categories in CKD GFR category GFR (ml/min/1.73 m 2 ) Terms G1> 90Normal or high G260-89Mildly decreased* G3a45-59Mildly to moderately Decreased G3b30-44Moderately to Severely decreased G415-29Severely decreased G5<15Kidney failure * Relative to young adult level In the absence of evidence of kidney damage, neither GFR category G1 or G2 fulfill the criteria for CKD. KDIGO 2012 Clinical Practice Guidelines for the Evaluation and Management of CKD Using CKD-EPI creatinine question or eGFR cys or eGFR creat-cys

9.  Assign albuminuria categories as follows (Not Graded): *note that where albuminuria measurement is not available, urine reagent strip results can be substituted CategoryAER (mg/24 hours) ACR (mg/mmol) ACR (mg/g) TERMS approximateequivalent A1< 30<3<30Normal to mildly increased A230-3003-3030-300Moderately increased* A3>300>30>300Severely increased** Albuminuria categories in CKD *Relative to young adult level ** Including nephrotic syndrome (albumin excretion usually > 2200 mg/24 hours [ ACR.2220/g; >220 mg/mmol]) KDIGO 2012 Clinical Practice Guidelines for the Evaluation and Management of CKD

10. G1Normal or high> 90 1 if CKD12 G2Mildly decreased60-89 1 if CKD12 G3a Mildly to moderately Decreased 45-59 123 G3bModerately to severely decreased 30-44 233 G4Severely decreased15-29 334+ G5Kidney Failure<15 4+ A1A2A3 Normal to Mildly Increased Moderately Increased Severely Increased < 30 mg/g < 3 mg/mmol 30-300 mg/g 3-30 mg/mmol >300 mg/g >30 mg/mmol Persistent albuminuria categories Description and range GFR categories (ml/min/1.73 m 2 Description and Range Guide to Frequency of Monitoring (number of times per year) by GFR and Albuminuria Category Green low risk (if no other markers of kidney disease, no CKD); Yellow: moderately increased risk; Orange: high risk; Red, very high risk. KDIGO 2012 Clinical Practice Guidelines for the Evaluation and Management of CKD

11. ESRD Patients2, 786, 000 Thereof HD1,929,000 Thereof PD235,000 Thereof Tx622,000 World Population 7.0 Billion Annual Growth Rates World population1.1% ESRD6-7% HD6-7% PD7-8% Tx4-5%

12. ESRD Patients in 2011; A Global Perspective, Frenesius Medical Care

13. Comparison of HD and PD patients numbers in the 15 largest countries ranked by total dialysis patient population

14. Percent Distribution of prevalent Dialysis patients, by modality 2010

15. PD use World Wide USRDS 8% of ESRD patients were on PD compared to 92% on hemodialysis. Data from other centers showed that  22% patients on PD in England  19% in Australia,  35 % in New Zealand  Hong kong 78%  Mexico 51%

16. ESRD Patients in 2011; A Global Perspective, Frenesius Medical Care 153,000 patients 82,000 patients

17. Dialysis Population-Current and Projected (1995-2015) Saudi J Kidney Dis Transplant 2012;23 (4):881-889

18. Causes of end-stage Renal Disease in HD Patients- 2011 Cause of Renal FailureNo% Diabetic Nephropathy451337.3 Hypertensive Nephropathy437536.1 Unknown Etiology11089.2 Primary Glomerular Disease7125.9 Obstructive Uropathy3202.6 Hereditary Renal Disease2241.8 Congenital Malformation2672.2 Primary Tubulo-interstitial Disease1481.2 Vasculitis1521.3 Pregnancy related660.5 Others2311.9 Total12116100 Saudi J Kidney Dis Transplant 2012;23 (4):881-889

19. Renal Replacement Therapy 2011 Total= 20, 764 Pts (765 PMP) Saudi J Kidney Dis Transplant 2012;23 (4):881-889

20. Treatment Modality 2011 Saudi J Kidney Dis Transplant 2012;23 (4):881-889

21. Integrated ESRD care Systematic “managed care” type strategies Intention of maximizing clinical outcome Minimizing cost

22. Integrated ESRD care Requires nephrologists to take a more integrated approach to their patients To manage them more systematically from first presentation with CRF through to their course on ESRD Include treatment with HD, PD and transplantation

23. Integrated dialysis care  HD and PD are complimentary rather than competitive dialytic therapies.  Every RRT has a technical “drop-out”, it is very likely that a patient will need several modalities during his lifetime and transfer from one technique to another will often be needed.  Patient survival and quality of life are two very important factors in the selection of a dialysis modality

24. Early referral of patients with CKD Patient education program Pre-emptive transplantation PD as first option if medically suitable allowing for patient to choose PD Transplant HD

25. Integrated Renal Care concept- what does it mean? The integrated care concept (acc. To Lameire N. et al. PDI, 2000; Van Biesen W.et al. PDI, 2000, Corles G. A. et al. Kidney Int. 1998) Peritoneal dialysis- the role in the integrated renal care, pitfalls and benefits of therapy Adv. Clin.Exp. Med.. 2003, 12,2,243-249

26. Integrated Renal Care concept- what does it mean? A broader concept of integrated care (acc. To Mendelssohn D. C., Pierratos A., PDI, 2002) Peritoneal dialysis- the role in the integrated renal care, pitfalls and benefits of therapy Adv. Clin.Exp. Med.. 2003, 12,2,243-249

27. Waiting List for Renal Transplantation among Dialysis Patients-2011 Total 12116 Saudi J Kidney Dis Transplant 2012;23 (4):881-889 Kidney Replacement Therapy: Modality Choice

28. Most patients are medically eligible for PD. PD has few absolute medical contraindications In a large Dutch study, only 17% patients had a medical contraindication to PD; (previous major abdominal surgery).

29. In a recent U.S. study, only 23% of ESRD patients had a medical contraindication to PD In studies from other countries 17% to 21%. 50% of patients preferred PD.  Burden of Therapy * Typical CHD unit have a very robust infrastructure Jager KJ etal. Am J Kidney Dis. 2004;43:891 ‐ 899

30.  PD-Related Complication Rates Are Decreasing. * Innovations in connection technologies catheter design use of prophylactic antibiotics improvement in catheter function and peritonitis and exit site infection rates.

31. Benefits of PD as the first modality of IRC  Higher survival in the first 3 years of renal replacement therapy (RRT)  Cardiovascular benefits, especially in elderly and diabetic patients  Better preservation of residual renal function (RRF)  Better quality of life (QoL) especially in flexibility and convenience  Better control of anemia Peritoneal dialysis- the role in the integrated renal care, pitfalls and benefits of therapy Adv. Clin.Exp. Med.. 2003, 12,2,243-249

32.  Better post transplanted outcome  Less infection and complications of infection  Lower prevalence of hepatitis C infections  Preserve vascular access  Less expensive than HD especially in the first 3 years of RRT. Peritoneal dialysis- the role in the integrated renal care, pitfalls and benefits of therapy Adv. Clin.Exp. Med.. 2003, 12,2,243-249

33. Higher survival in first 1-3 years of RRT Data from the 2008 report suggest that there was no difference in the 60-month survival probability between PD and CHD for the population as a whole These USRDS observations suggest that patients who start their RRT on PD have a survival advantage over similar patients on CHD. Survival in non-diabetic and young diabetic patients in the first two years of PD. Advantage of PD surivival over HD is lost after one to three years of dialysis, especially in older diabetic patients Survival of patients on CAPD up to 2 years was 84% and 82% on HD. Peritoneal dialysis- the role in the integrated renal care, pitfalls and benefits of therapy Adv. Clin.Exp. Med.. 2003, 12,2,243-249

34. Mortality Rates: ERDTA - 149 deaths per 1,000 patient years, USRDS - 125 deaths per 1,000 patient years. Patient mortality at King Khalid University Hospital was  7.81 % or 95 deaths per 1000 patient years

35. Cardiovascular Benefits especially in elderly and diabetic patients  Superior survival among PD patients over HD patients in first years of RRT  Better control BL pressure,fluid load, anemia,LVH  Better control of cardiovascular problems with PD is the main reason for transfer HD patients to PD  PD are better arryhthmia control, lower homocysteine level and better anemia control

36. Better Preservation of RRF Residual renal function  In most CAPD patients RRF is preserved up to 3 rd year of therapy.  This is probable the cause of better survival in comparison to PD patients being dialysed longer than 3 years.  Tattersall and co-workers reported better survival and lower hospitalization rate of PD patients with higher RRF Peritoneal dialysis- the role in the integrated renal care, pitfalls and benefits of therapy Adv. Clin.Exp. Med.. 2003, 12,2,243-249

37.  Quality of Life-Related Issues *Current data do not show a consistent difference between studies in SF 36 ratings between PD and HD overtime. *There is a consistent trend that favors PD. *PD patients tend to be more satisfied with their therapy than CHD patients.

38. Recent Publication Ann Saudi Med 2012; 32(6): 570-574

39. Quality of Life Scores of Hemodialysis and Peritoneal dialysis patients Quality of life in hemodialysis and peritoneal dialysis patients in Saudi Arabia Ann Saudi Med 2012; 32(6): 570-574

40. Better Control of Anemia  Need lower doses of rHUEPO for achievement of appropriate values.  Longer preservation of RRF, peritoneal membrane being more biocompatible dialysing membrane, lower blood losses, no anticoagulation.  Lower doses of intravenous iron. Peritoneal dialysis- the role in the integrated renal care, pitfalls and benefits of therapy Adv. Clin.Exp. Med.. 2003, 12,2,243-249

41.  Transplant-Related Issues *Multiple retrospective cohort observational studies transplanted form PD, less like to have delayed graft survival. *Patients transplanted from PD had >6% lower risk of death ; > 3% lower risk of graft failure than those transplanted from HD.

42. Infections In a 3 year study rates are the same, but the types of infection differ HD related infections often more severe and lead to higher mortality risks * Septicaemia incidence 22%, mortality rate 20% * Pneumonia 17% * Exit site 37% PD related infections have a lower mortality rate * Peritonitis incidence 24%, mortality rate 2.3% * Pneumonia 3% * Exit site 53%

43. Morbidity of infections PD Catheter removal <5% Endocarditis/Osteomyelitis—unmeasurable HD Catheter (graft) removal 80% Systemic infection—15%

44. Lower prevalence of hepatitis C infection Hepatitis C virus is a major cause of morbidity and mortality in RRT patients. Hepatitis C virus (HCV) infects an estimated 170 million people worldwide. Prevalence of HCV in hemodialysis (HD) patients ranges from 3 to 23% in developed countries and exceeds 50% in some developing countries. HCV-infected HD patients have higher mortality rates than noninfected HD patients, with reported relative risks from 1.25 to 1.57. Clin J Am Soc Nephrol 4: 1449–1458, 2009. doi: 10.2215/CJN.018503

45. HBsAg and HCV Among HD Patients-2011 HBsAG HCV Total 12116 Saudi J Kidney Dis Transplant 2012;23 (4):881-889

46. Dialysis in the Kingdom of Saudi Arabia Active Peritoneal Dialysis Patients Total 1240 Saudi J Kidney Dis Transplant 2012;23 (4):881-889

47. HCV Antibodies Status- 2011 Saudi J Kidney Dis Transplant 2012;23 (4):881-889

48. Preservation of vascular access: 33% of all hemodialysis patients use a central venous catheter Access complications 25% hospitalizations 30% catheter failure rate high incidence of bacteremia (40%) in hemodialysis patients Life of AVF 2.5 years Premature use causes loss of AVF 30% In the life of a dialysis patient—two-three years is a long time without an access issue

49. Cost of Utility Studies on cost utility between PD and HD performed in Europe and North America showed that HD is 10-70% more expensive than PD especially in the first years of dialysis. Increasing use of APD in recent years diminished cost advantage of PD. Peritoneal dialysis- the role in the integrated renal care, pitfalls and benefits of therapy Adv. Clin.Exp. Med.. 2003, 12,2,243-249

50. Patient benefits from PD: Independence and control Dialysis in bed Flexibility around day to day life No travel to hospital No needles Ability to travel Self reported QOL superiority

51. a) Choose of dialysis should integrate with daily activities such as work, school, hobbies, family commitments and travel for work or leisure. 1.1.9) Offer all people with stage 5 CKD a choice of peritoneal dialysis or hemodialysis, if appropriate but consider peritoneal dialysis as the first choice of treatment modality for: children 2 years old or younger people with residual function adults without significant associated comorbidities. NICE Clinical Guidelines 125-Peritoneal Dialysis NICE Clinical Guidelines 2011(UK)

52. 1.1.11)Before starting peritoneal dialysis, offer all patients a choice, if appropriate, between CAPD and APD (or aAPD if necessary). 1.1.13)Do not routinely switch patients on peritoneal dialysis to a different treatment modality in anticipation of potential future complications such as encapsulating peritoneal sclerosis. However, healthcare professionals should monitor risk factors such as loss of ultrafiltration and discuss with patients regularly the efficacy of all aspects of their treatment. NICE Clinical Guidelines 125-Peritoneal Dialysis NICE Clinical Guidelines 2011

53. Integrated Care Approach “ Start renal replacement therapy in ESRD patients with PD, transfer them to HD when problems with PD occur, and transplant them when the possibility exists.” Lamiere N, et al, Seminar of Uro-Nephrology. (1999) CONCLUSION: Lamiere N

54. 14 th Congress of International Society for Peritoneal Dialysis 9 th -12 September 2012, Kuala Lumpur, Malaysia