Effect of Kt/V on survival and clinical outcome in CAPD patients in a randomized prospective study

Lo, Wai-Kei; Ho, Yiu‐Wing; Li, Chun-Sang; Wong, Kin-Shing; Chan, Tak‐Mao; Yu, Alex W.; Ng, Flora; Cheng, Ignatius K.P.

doi:10.1046/j.1523-1755.2003.00098.x

Cited by 233 publications

(176 citation statements)

References 21 publications

(18 reference statements)

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“…On the one hand, the greater membrane solute transport rate will enhance small solute clearance (although not necessarily during more prolonged dwells [45]); on the other hand, it may enhance protein losses, leading to malnutrition and diminished fluid removal. Recent randomized trials and observational studies now support the notion that peritoneal solute clearance does not significantly influence patient outcome within usual PD dosing regimens (22,46,47), whereas clinical volume status may (15,46,48,49). Our meta-analysis is consistent with these observations.…”

Section: Discussionsupporting

confidence: 81%

Meta-Analysis

Brimble¹,

Walker²,

Margetts³

et al. 2006

Journal of the American Society of Nephrology

234

202

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Peritoneal membrane solute transport in peritoneal dialysis (PD) patients is assessed by the peritoneal equilibration test, which measures the ratio of creatinine in the dialysate to plasma after a standardized 4-h dwell (D/P c ). Patients then are classified as high, high-average, low-average, or low transporters on the basis of this result. A meta-analysis of observational studies was carried out to characterize the relationship between D/P c and mortality and technique failure in patients who are on PD. Citations were identified in Medline by using a combination of Medical Subject Heading search terms and key words related to PD, peritoneal membrane permeability/transport, and mortality and technique failure. The table of contents of relevant journals and bibliographies of relevant citations were reviewed in duplicate. Twenty studies that met study criteria were identified. Nineteen studies were pooled to generate a summary mortality relative risk of 1.15 for every 0.1 increase in the D/P c (95% confidence interval 1.07 to 1.23; P < 001). This result equated to an increased mortality risk of 21.9, 45.7, and 77.3% in low-average, high-average, and high transporters, respectively, as compared with patients with low transport status. Meta-regression analysis showed that the proportion of patients who were on continuous cycler PD within a study was inversely proportional to the mortality risk (P ‫؍‬ 0.05). The pooled summary relative risk for death-censored technique failure was 1.18 (95% confidence interval 0.96 to 1.46; P ‫؍‬ 0.12) for every 0.1 increase in the D/P c . This meta-analysis demonstrates that a higher peritoneal membrane solute transport rate is associated with a higher mortality risk and a trend to higher technique failure.J Am Soc Nephrol 17: 2591 -2598, 2006 . doi: 10.1681 P atients with ESRD, including those who are on peritoneal dialysis (PD), are at a much higher risk for premature death than the general population. Well-accepted risk factors for early mortality that have been identified in the PD population include age, diabetes, preexisting cardiovascular disease, and malnutrition/hypoalbuminemia (1-6).The peritoneal equilibration test (PET) characterizes the peritoneal membrane transport properties by determining the ratio of the creatinine concentration in the dialysate to that in the plasma after a 4-h dwell (D/P c ) and has been shown to vary considerably among individuals (7). Patients with a greater rate of membrane solute transport (i.e., higher D/P c ) will tend to have enhanced clearance of small solutes, including urea and creatinine, during shorter dwells. However, these patients will have greater peritoneal losses of protein, will be more prone to fluid retention as a result of rapid reabsorption of glucose from the dialysate and subsequent ultrafiltration dysfunction, and will have greater systemic exposure to glucose. These differences may have competing effects on both patient and technique survival such that from a biologic basis, it is unclear what, if any, the effect of pe...

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Section: Discussionsupporting

confidence: 81%

Meta-Analysis

Brimble¹,

Walker²,

Margetts³

et al. 2006

Journal of the American Society of Nephrology

234

202

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“…Patient survival on PD in The Netherlands has somewhat improved over the past 10 years (3). The rate we found corresponds with that found in another national study (21), is higher than rates reported from some American studies (4,7), and is somewhat lower than in Asian studies (22,23).…”

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confidence: 51%

Time-Dependent Reasons for Peritoneal Dialysis Technique Failure and Mortality

et al. 2010

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♦♦ ♦♦ ♦ Background: Peritoneal dialysis (PD) technique failure is high compared to hemodialysis (HD). There is a lack of data on the impact of duration of PD treatment on technique survival and on whether there is a difference in risk factors with respect to early and late failure. The aim of this study was to clarify these issues by performing a timedependent analysis of PD technique and patient survival in a large cohort of incident PD patients. ♦♦ ♦♦ ♦ Methods: We analyzed 709 incident PD patients participating in the Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD), who started their treatment between 1997 and 2007. We compared technique and patient survival on PD in 4 periods of follow-up: within the first 3 months, and after 3 -12 months, 12 -24 months, and 24 -36 months of treatment. Cox proportional hazards model was used to analyze survival on PD and technique failure. Risk factors were also identified by comparing patients that were transferred to HD with those that remained on PD. Incidence rates for every cause of dropout for each period of follow-up were calculated to establish their trends with respect to PD treatment duration. ♦♦ ♦♦ ♦ Results: There was a significant increase in transplantation rate after the first year of treatment. The rate of switching to HD was highest during the first 3 months and decreased afterward. One-, 2-and 3-year technique survival was 87%, 76%, and 66%, respectively. Age, diabetes, and cardiovascular disease appeared to be risk factors for death on PD or switch to HD: a 1-year increase in age was associated with a relative risk (RR) of PD failure of 1.04 [95% confidence interval (CI) 1.003 -1.06]; for diabetes, RR of stopping PD after 3 months of treatment increased from 1.8 (95% CI 1.1 -3) during the first year to 2.2 (95% CI 1.3 -4) after the second year; cardiovascular disease had a major impact in the earliest period (RR 2.5, 95% CI 1.2 -5) and had a stable influence further on (RR 2, 95% CI 1.1 -3.5).Loss of 1 mL/minute residual glomerular filtration rate (rGFR) appeared to be a significant predictor of PD failure after 3 months of treatment, but within the first 2 years, RR was 1.1 (95% CI 1.04 -1.25). ♦♦ ♦♦ ♦ Conclusions: In The Netherlands, transplantation is a main reason to stop PD treatment. The incidence of PD technique failure is at its highest during the earliest months after treatment initiation and decreases later due to fewer catheter and abdominal complications as well as less influence of psychosocial factors. Risk factors for PD discontinuation are those responsible for patient survival: age, cardiovascular disease, diabetes, and rGFR.

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“…Previously, adequacy targets for peritoneal dialysis (PD) patients were founded on both urea and creatinine kinetics based on the original interpretation of the results from the CANUSA trial (1). In recent years, minimum adequacy targets for PD patients have been altered based upon results from the ADEMEX and Hong Kong trials (2,3). The ADEMEX trial found no difference in survival of patients who received an average urea Kt/V of 1.80 or 2.27, and the Hong Kong trial similarly found no improvement in survival if patients received urea Kt/V of greater than 1.5 -1.7.…”

mentioning

confidence: 99%

Volume-Based Peritoneal Dialysis Prescription Guide to Achieve Adequacy Targets

et al. 2015

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♦ Background: The use of automated and continuous ambulatory peritoneal dialysis (APD and CAPD) prescriptions (Rxs) to achieve adequate uremic toxin and fluid removal targets is important for attaining optimal patient outcomes. One approach for predicting such Rxs is the use of kinetic modeling. ♦ Methods: Demographic data and peritoneal membrane characteristics derived from a peritoneal equilibration test (PET) were available from 1,005 patients in North American centers who participated in a national adequacy initiative in 1999. Twelve patient subgroups were identified according to peritoneal membrane transport type and tertiles of total body water, assumed equal to urea distribution volume (V urea ). Each patient was then modeled using PD Adequest 2.0 to be treated by 12 CAPD and 34 APD Rxs using both glucose and icodextrin solutions to achieve adequacy targets of weekly urea Kt/V of 1.7 and 1 L of daily ultrafiltration (UF). Residual kidney function (RKF) was assumed to be 0, 2, 4, and 6 mL/min. Feasible peritoneal dialysis (PD) Rxs were identified where: 1) the 95% confidence limit achieved the goal of meeting the targets for urea Kt/V, daily UF, and both in 85%, 75%, and 70% of patients, respectively; 2) average PD solution dextrose concentration was < 2.5%; and 3) the number of daytime exchanges was minimized. ♦ Results: Feasible PD Rxs were similar when RKF was ≥ 2 mL/min, allowing condensed recommendations based on RKF ≥ 2 mL/min or < 2 mL/min. Individuals with lower or slower membrane transport required relatively greater 24-h solution volumes to achieve adequacy targets when RKF fell below 2 mL/min. With increasing V urea , there was disproportionately greater dependence on RKF to achieve targets. While multiple Rxs achieving urea Kt/V and daily UF goals were identified for all membrane transport types, use of icodextrin in the long dwell reduced the need for a midday exchange in APD, glucose exposure, required fill and 24-h dwell volumes, irrespective of RKF and V urea . While these benefits were most notable in high and high-average transporters, similar results were also seen in low and low-average transporters.

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Effect of Kt/V on survival and clinical outcome in CAPD patients in a randomized prospective study

Cited by 233 publications

References 21 publications

Meta-Analysis

Meta-Analysis

Time-Dependent Reasons for Peritoneal Dialysis Technique Failure and Mortality

Volume-Based Peritoneal Dialysis Prescription Guide to Achieve Adequacy Targets

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