Changes in Peritoneal Dialysis Practices in Canada 1996 – 1999

Abstract

← Objective Over the past decade, clinical studies and clinical practice guidelines have suggested the use of higher small solute clearance targets for patients on peritoneal dialysis (PD). This study asks whether these recommendations have translated into changes in clinical prescription of PD. ← Study Design Data were collected annually from 1996 to 1999 on all prevalent dialysis patients in 24 Canadian centers, accounting for approximately 40% of the Canadian chronic dialysis population. Approximately a third of these patients were on PD. Full details of each patient's prescription were recorded, with particular attention to dwell volumes and frequency of exchanges for continuous ambulatory PD (CAPD) and to total treatment volumes and day dwells for automated PD (APD). The most recent Kt/V and creatinine clearance values available were recorded for each patient and the overall results for each year were compared to present treatment recommendations. ← Setting 24 university- and community-based hospitals. ← Results From 1996 to 1999, the use of APD, relative to CAPD, grew from 14% to 28% of all PD patients. Among CAPD patients, the proportion using dwell volumes greater than 2 L rose from 14% to 32%, and the proportion doing more than 4 dwells per day rose from 16% to 28%. The mean daily volume of prescribed fluid for CAPD patients increased from 8.3 to 9.1 L. As a result, the proportion of patients achieving a weekly Kt/V above 2.0 rose from 54% to 72%, and those receiving a Kt/V less than 1.7 fell from 22% to 10%. For creatinine clearance, those exceeding 60 L per week rose from 63% to 73%. For APD, the mean treatment volume rose from 11.8 L in 1996 to plateau at about 13.4 L in 1998 and 1999. However, the proportion of patients receiving more than 1 day dwell grew from 31% in 1998 to 40% in 1999, and the proportion that were “day dry” fell from 25% to 17%. For APD, the proportion of patients with a Kt/V above 2.0 rose from 67% to 77%, and with a creatinine clearance above 60 L, from 62% to 70%. The proportion with no recent clearance value recorded fell during the course of the study, from 45% to 27%. ← Conclusion There was a marked change in PD prescription practices in Canada during the second half of the 1990s. This occurred in response to clinical studies and publication of guidelines. There is room for further improvement, especially with respect to the proportion of patients that did not have regular clearance measurements made.

The Brazilian Peritoneal Dialysis Multicenter Study (BRAZPD): Characterization of the cohort

“…We observed a very large number of both incident and prevalent patients on APD. We also observed that the standard prescription for APD is similar to that seen in other studies, 12 which provides a great opportunity for analyzing the outcome of APD patients in comparison to CAPD. With regard to dialysis prescription there was a large percentage of patients using hypertonic solutions, which could reflect the profile of PD patients in Brazil, many coming from HD already anuric.…”

“…It should be noted that the ADEMEX study, although of interventional design, provides an important source of epidemiological and clinical information in a large (965) number of patients. 19 Additionally, registries such as the COOR, 12 USRDS, 13 NECOSAD, 14 and ANZDATA 17 are numerically very large and perhaps most importantly, provide continued information regarding characteristics of the PD population, complications of the method, survival, quality of life, comparison between subgroups, as well as comparison with HD. The sample evaluated in BRAZPD corresponds to 48% of the patients on PD in Brazil, which is representative, and allows for extrapolation of conclusions to the overall PD population in the country.…”

“…The large observational national registries available 12,13,17,23 reflect more homogenous geographic characteristics. Some studies have correlated geographic variables in PD, demonstrating a greater indication of this modality for populations geographically distant from the dialysis centers.…”

“…[7][8][9][10] Observational studies, which can be exploratory or confirmatory in nature, serve as the important substrate for generating interesting ideas to be tested in the appropriate clinical studies to generate medical evidence. Several observational studies have been important in shifting paradigms in the field of PD, such as the multicenter studies in the United States and Canada (CANUSA): 11 COOR, 12 USRDS; 13 Europe: NECOSAD, 14 EAPOS; 15 Asia: ASPD; 16 and Australasia: ANZDATA. 17 So far, the data on clinical practice and long-term results on PD in Latin America are restricted to the REDTJAL study in Mexico.…”

The Use of Incremental Peritoneal Dialysis in a Large Contemporary Peritoneal Dialysis Program

“…This was also based on the 1997 Guideline and on widely used PD practices in Canada in previous surveys. 14 It is recognized that standard PD prescriptions may differ between countries. 15 These “Full-Dose PD” patients can be subdivided into those who achieve the Kt/V target with peritoneal Kt/V alone and those who achieve it through a combination of both peritoneal and residual renal clearance.…”