SummaryBackground and objectives This study assessed whether assisted peritoneal dialysis (PD) was associated with a lower risk for technique failure using methods developed for survival analysis in the presence of competing risks. Results There were 5286 patients undergoing assisted PD; 4230 of these were assisted by a community nurse and 1056 by family. Assisted PD patients were older and had a higher Charlson comorbidity index than self-care PD patients. There were 7594 events: 3495 deaths, 2464 transfers to hemodialysis, 1489 renal transplantations, and 146 renal function recoveries. According to a Cox model, assistance and center size were associated with a lower risk for technique failure, whereas hemodialysis before PD, early peritonitis, and transplantation failure were associated with a higher risk for transfer to hemodialysis. A Fine and Gray regression model showed that assisted PD was associated with a lower risk for transfer to hemodialysis. ConclusionsCompared with patients undergoing self-care PD, those with assisted PD had a lower risk for transfer to hemodialysis, a higher risk for death, and a lower risk for transplantation.

PD is a suitable method for elderly patients. In order to increase the rate of PD utilization in elderly patients, the need for the funding of assisted peritoneal dialysis has to be taken into account.

APD patients assisted at home by a private nurse have a higher risk of developing peritonitis than family-assisted patients, unless additional regular home visits are organized by the original training centre. Therefore, we recommend that home visits be regularly made for dependent PD patients to optimize the quality of care provided by the helper.

The competing risk approach shows that the CI of at least one peritonitis episode was lower than reported by the Kaplan-Meier method but that survival peritonitis-free and still on PD was overall low. The competing risk approach provides estimates which have a clearer interpretation than Kaplan-Meier methods and could be more widely used in PD research.

A B S T R AC TBackground. This study was carried out to examine the association of sub-optimal dialysis initiation of peritoneal dialysis (PD) with all the possible outcomes on PD using survival analysis in the presence of competing risks. Methods. This was a retrospective cohort study based on the data of the French Language Peritoneal Dialysis Registry. We analysed 8527 incident patients starting PD between January 2002 and December 2010. The end of the observation period was 01 June 2011. Times from the start of PD to death, transplantation, transfer to haemodialysis (HD) and first peritonitis episode were calculated. The sub-optimal dialysis initiation was defined by a period of <30 days on HD before PD initiation. Results. Among 8527 patients, there were 568 patients who started PD after <30 days on HD. There were 6562 events: 3078 deaths, 2136 transfers to HD, 1348 renal transplantations. When using a Fine and Gray model, sub-optimal dialysis start, early peritonitis and transplant failure were associated with a higher sub-distribution relative hazard of technique failure. There was no association between the suboptimal dialysis start and the sub-distribution hazard of death or transplantation. In the multivariate analysis using a Fine and Gray regression model, the sub-optimal dialysis start was not associated with a higher sub distribution relative hazard of peritonitis. Conclusions. Sub-optimal dialysis initiation is neither associated with a higher risk of death nor with a lower risk of renal transplantation. Sub-optimal PD patients had a higher risk of transfer to HD.