Predictors of Renal Recovery in Australian and New Zealand end-Stage Renal Failure Patients Treated with Peritoneal Dialysis

Abstract

Objectives The aim of this study was to investigate the factors affecting recovery and durability of dialysis-independent renal function following commencement of peritoneal dialysis (PD). Design Retrospective, observational cohort study of the Australian and New Zealand PD patient population. Setting Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry. Participants The study reviewed all patients in Australia and New Zealand who commenced PD for treatment of end-stage renal failure between 15 May 1963 and 31 December 2004. Main Outcome Measures The primary outcomes examined were recovery of dialysis-independent renal function and time from PD commencement to recovery of renal function. A secondary outcome measure was time to renal death (patient death or recommencement of renal replacement therapy) following recovery of dialysis-independent renal function. Results 24663 patients commenced PD during the study period. Of these, 253 (1%) recovered dialysis-independent renal function. An increased likelihood of recovery was predicted by autoimmune renal disease, hemolytic-uremic syndrome, paraproteinemia, cortical necrosis, renovascular disease, and treatment in New Zealand. A reduced likelihood of recovery was associated with polycystic kidney disease and indigenous race. Analysis of a contemporary subset of 14743 patients in whom complete data were available for body mass index, smoking, and comorbidities yielded comparable results, except that increasing age was additionally associated with a decreased likelihood of recovery. Of the 253 patients who recovered renal function, 151 (60%) recommenced renal replacement therapy and 49 (19%) died within a median period of 226 days (interquartile range 110 – 581 days). The only significant predictors of continued renal survival after renal recovery were autoimmune renal disease and cortical necrosis. Conclusions Recovery of renal function in patients treated with PD is rare and determined mainly by renal disease type and race. In the majority of cases, recovery is short term. The apparently high rate of early patient death or return to dialysis after recovery of renal function on PD raises questions about the appropriateness of discontinuing PD therapy under such circumstances.

Tailoring dialysis and resuming low‐protein diets may favor chronic dialysis discontinuation: Report on three cases

“…The three case reports, regarding patients who were all treated at a small dialysis Unit where a "tailor-made," highly personalized dialysis regimen is pursued, may offer a few ideas for discussion, in the context of the recent medical literature, that suggest that RFR, allowing discontinuation of dialysis, may occur more frequently than is generally believed. [13][14][15][16][17][18][19][20] While there is undoubtedly a quota of serendipity in the observation of a high prevalence of RFR in our series, linked to the small number of treated patients, this experience may suggest that small settings, which allow for a policy of highly personalized treatment, may be particularly suitable for enhancing kidney function recovery. Indeed, in our opinion, the individualized follow-up policy modulated the clinical decisions mainly on the basis of dialysis tolerance: we were quite reluctant to discontinue hemodialysis in our first patient, with good dialysis tolerance; conversely, in the other two patients, dialysis was withdrawn relatively early (i.e., when GFR was still below 10 mL/min) on account of poor tolerance to the dialysis sessions (Table 1).…”

“…13 The ANZ data registry has dedicated a series of analyses to RFR; the studies report an overall incidence of 1%, without differences in hemodialysis and peritoneal dialysis (PD), but with wide differences according to the renal diseases (up to 10% in scleroderma patients). [14][15][16][17] In other large series published since 2000, the incidence of RFR ranges from 2% to over 30%, the highest rates being recorded in severe hypertension and cholesterol emboli syndrome. [18][19][20] The definition of RFR is quite elusive, and the duration of dialysis after which kidney failure is considered as chronic ranges from 1 to 3 months.…”

“…[18][19][20] The definition of RFR is quite elusive, and the duration of dialysis after which kidney failure is considered as chronic ranges from 1 to 3 months. [14][15][16][17][18][19][20] Almost surprisingly, one of the clearest definitions of "chronic" dialysis stems from the studies on acute kidney injury: the RIFLE criteria define end-stage renal disease as the need for renal replacement therapy for more than 3 months. 21 With this in mind, we will report on three patients with severe multiple comorbidities who recovered from a dialysis-dependent state after more than 3 months of hemodialysis.…”

Renal Function Recovery in Chronic Dialysis Patients

“…Craven et al, after adjusting for the effects of comorbidities and lifestyle risk factors, found no statistically significant independent association of RFR with age, gender, or any other comorbidity. However, after adjustment for smoking, BMI and comorbidities in a subset of 14,743 patients in whom such data were available, a lower likelihood of RFR was found in older patients (7).…”

“…Notably, RFR rates are higher in all of the smaller single-center studies, ranging from 2.8% to 5.6%, compared to rates of 1.0-2.4% in large studies using data from kidney registries ( Table 1). The largest registry study analysis by Craven et al (7) reviewed all incident peritoneal dialysis (PD) in Australia and New Zealand between 1963 and 2004 and demonstrated the lowest RFR rate of 1.0%; a follow-up of these data reviewing patients from 1963 to 2006 revealed that the RFR rate remained at 1.0% for HD and 1.1% for PD (8).…”